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Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;87:4809-4822.
Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.
Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;77:1381-1395.
Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.

Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.
Hess E, Palmer SE, Stivers A, et al. J Oncol Pharm Pract. 2020;26:787-793.
This study used one cancer hospital’s incident reporting system to evaluate trends in medication error reporting before and after the implementation of a new electronic health record (EHR) system. After implementation, decreases in reporting were observed for wrong-dose, overdose, wrong duration, and wrong frequency medication errors, likely due to EHR tools such as hard stops on medication doses or prohibiting early or late administration.
Daupin J, Perrin G, Lhermitte-Pastor C, et al. J Oncol Pract. 2019;25:1195-1203.
Prior research has shown that oncology pharmacists can improve the safety of chemotherapy administration. In this prospective study, researchers found that 129 of 1346 chemotherapy prescriptions issued in a 1-month period at a single university hospital required intervention by an oncology pharmacist. The majority of such interventions were perceived as having a significant impact on patient safety.
Lloyd M, Watmough SD, O'Brien S, et al. Res Social Adm Pharm. 2018;14:936-943.
This study examined prescriber perceptions of a feedback intervention in which pharmacists told prescribers about their errors in order to improve future prescribing. Prescribers received such feedback positively, and the authors recommend systematizing prescribing feedback to enhance medication safety.
Shah D, Manzi S. Pediatr Emerg Care. 2018;34:497-500.
Clinical pharmacist supervision improves medication safety in many health care settings. In this study, pharmacists in a pediatric emergency department (ED) reviewed all discharge prescriptions the day after patients left the ED and contacted prescribers to address safety hazards. Over a 1-year period, pharmacists intervened rarely (0.25% of prescriptions), averted 10 incidents of moderate or major harm, and worked 45 additional minutes per day.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 30, 2015.
Look-alike and sound-alike drug names can contribute to confusion and result in medication errors. To raise awareness of potential wrong-patient errors due to similarity between two proprietary names, this announcement describes near misses with the drugs at the prescribing and dispensing stage and suggests clinicians use the generic names for the medications to reduce risk of patient harm.
Patterson ME, Pace HA. J Patient Saf. 2016;12:114-7.
This cross-sectional analysis sought to determine how a punitive work environment, poor feedback about errors, and inadequate preventive processes affect near-miss reporting by hospital pharmacists. Using data from the AHRQ Hospital Survey of Patient Safety Culture, researchers found that pharmacists who believed error prevention procedures and error feedback to be insufficient were less likely to report near misses. A work culture in which individuals are blamed for errors was also tied to less near-miss reporting, similar to other studies of safety culture. This study underscores the consistent finding that frontline health care personnel are more likely to participate in safety efforts when they perceive that their workplace is receptive to error reporting and develops interventions to address concerns raised. A previous AHRQ WebM&M perspective explores the evidence on safety culture over the past decade.
Boyle TA, Bishop AC, Overmars C, et al. J Pharm Pract. 2015;28:442-9.
This analysis of community pharmacy practices found that while most have reporting of medication errors and near misses in place, few establish improvement plans or apply systems approaches to address errors. This finding underscores the need to learn from events and implement changes to resolve safety issues.
Smith HS, Lesar TS. The journal of pain : official journal of the American Pain Society. 2011;12:29-40.
This analysis of analgesic prescribing near misses found that pediatric patients were most vulnerable to prescribing errors, and clinicians most frequently committed errors when prescribing medications that can be given by multiple routes of administration (i.e., intravenously and orally).
Tamuz M, Franchois KE, Thomas EJ. Saf Sci. 2010;49.
This case study examines an organizational response to a serious adverse event—a medication error in the intensive care unit that caused serious patient harm. Although a root cause analysis (RCA) was eventually convened, resulting in implementation of a systematic solution, prior to the RCA each professional group involved (nurses, pharmacists, and physicians) had already decided on individual approaches and solutions to the error. This resulted in unnecessary conflict and delays in reaching a workable solution to the problem.

Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.

This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.