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Iredell B, Mourad H, Nickman NA, et al. Am J Health Syst Pharm. 2022;79:730-735.
The advantages of automation can be safely achieved only when the technologies are implemented into processes that support their proper use in regular and urgent situations. This guideline outlines considerations for the safe use of computerized compounding devices to prepare parenteral nutrition admixtures with the broader application to other IV preparations in mind. Effective policy, training, system variation, and vendor partnerships are elements discussed.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.

Am J Health Syst Pharm. 2022;79(7): 564-599.

Pharmacists have a central role in ensuring medication safety during healthcare delivery. This report outlines standards for the delivery of safe, high-quality pharmacy services including how pharmacy departments should be placed within the health system and how health system processes can support safe medication use and pharmacy practice.
Am J Health-Syst Pharm. 2020;77:308-312.
This piece highlights the value of a medication safety leader in guiding error prevention efforts and outlines the responsibilities of such a role. Areas of focus include leadership, medication safety expertise, change management, research and education.
Bickham P, Golembiewski J, Meyer T, et al. Am J Health Syst Pharm. 2019;76:903-820.
Pharmacists working with surgical teams bring distinct safety context, expertise, and process awareness to perioperative care. These guidelines outline how pharmacists can help reduce medication errors before, during, and after surgery. Perioperative pharmacists can enhance communication, medication histories, and process reliability.

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Billstein-Leber M, Carrillo CJD, Cassano AT, et al. Am J Health-Syst Pharm. 2018;75:1493-1517.
Pharmacists can play an important role in medication error reduction efforts across health care systems. This document provides recommendations and best practices for health-system pharmacists to improve safety throughout the medication-use process.
Eiland LS, Benner K, Gumpper KF, et al. J Pediatr Pharmacol Ther. 2018;23:177-191.
Pediatric patients are at particularly high risk for medication errors. Challenges pharmacists face when providing care for children include a lack of standard dosage forms and concentrations and patient inability to describe symptoms. These guidelines provide practical recommendations to improve the safety of pediatric pharmacy services.
Horsham, PA: Institute for Safe Medication Practices; May 2017.
Insulin is a widely used medication that can contribute to serious patient harm if used incorrectly. This report provides information about problems associated with insulin use in adults and offers consensus-developed strategies to encourage subcutaneous insulin practices that reduce errors at the prescribing, pharmacy management, administration, and transition phases.
Bethesda, MD: American Society of Health-System Pharmacists; 2016.
Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first phase of a standards development project, this report describes how standardization can improve reliability and safety of intravenous therapy and provides guidance on safe concentrations for drugs.
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65:1-49.
Opioid pain medications carry high risk for adverse drug events and misuse. Due to climbing rates of opioid use and associated adverse events, the Centers for Disease Control and Prevention released new guidelines for prescribing opioid medications for chronic pain. These guidelines do not apply to patients receiving cancer treatment, palliative care, or end-of-life care. The authors recommend using opioids for chronic pain only if nonopioid medications and nonpharmacologic approaches to chronic pain are not effective and prescribing immediate-release instead of long-acting medications. For acute pain, they recommend limiting duration of therapy, stating that more than 1 week of medications should rarely be needed. The guidelines also suggest minimizing concurrent use of opioids and other sedating medications and dispensing naloxone to prevent overdoses. A previous WebM&M commentary describes an adverse event related to opioids.
Buxton JA, Babbitt RM, Clegg CA, et al. Am J Health-Syst Pharm. 2015;72:1221-1236.
Ambulatory pharmacy service is provided in various settings, including communities, skilled nursing facilities, and patient-centered medical care homes. Elements related to safety in this environment include leadership, patient care, distribution, and facility characteristics. This American Society of Health-System Pharmacists guideline reviews eight standards that can be adapted to support safe medication delivery in a wide range of ambulatory settings.
Goldspiel B, Hoffman JM, Griffith NL, et al. Am J Health Syst Pharm. 2015;72:e6-e35.
The American Society of Health-Systems Pharmacists developed these guidelines to apply medication safety best practices to the delivery of chemotherapy and biotherapy agents. These recommendations include sets of specific actions for the overall health care system and for frontline providers.
Testimony before the Committee on Health, Education, Labor, and Pensions, US Senate. US Government Accountability Office. GAO-12-315T (December 15, 2011)
This testimony details the US Food and Drug Administration (FDA) response to drug shortage trends and advocates for the agency to have more leverage with manufacturers to address burgeoning shortages.

Hearings before the Subcommittee on Health of the Committee on Energy and Commerce Committee, 112th Cong, 1st Sess (September 23, 2011).

This hearing focused on the problem of medication shortages and its impact on patients, hospitals, and providers.