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This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Mello MM, Roche S, Greenberg Y, et al. BMJ Qual Saf. 2020;29:895-904.
Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving the patient safety issue, but successful implementation has been challenging. This study used qualitative methods to explore factors supporting successful CRP implementation at two Massachusetts hospitals. Identified facilitators of successful implementation encompassed institutional leadership support including oversight by a full-time project manager, investments in physician training, positive relationships between hospital risk management and the liability insurer, use of formal decision protocols, collaborative group implementation, and small hospital size.
Hong K, Hong YD, Cooke CE. Res Social Adm Pharm. 2019;15:823-826.
Medication errors are common in inpatient and ambulatory environments. This commentary summarizes the research exploring the current status of medication safety incident reporting and reduction efforts in community pharmacies. The authors call for community pharmacy corporations to encourage the discussion and data sharing needed to increase transparency around incidents in this care setting. A recent PSNet interview discussed challenges to safety in the retail pharmacy environment.