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Jaam M, Naseralallah LM, Hussain TA, et al. PLoS One. 2021;16:e0253588.
Including pharmacists can improve patient safety across the medication prescribing continuum. This review identified twelve pharmacist-led educational interventions aimed at improving medication safety. The phase, educational strategy, patient population, and audience varied across studies; however most showed some reductions in medication errors.
Aghili M, Neelathahalli Kasturirangan M. JBI Evid Implement. 2021;19:21-30.
This study evaluated the impact of clinical pharmacist-led interventions on medication errors and preventable adverse drug events among patients in the ICU. The clinical pharmacist performed medication chart review, patient monitoring, and attended medical rounds in order to evaluate the appropriateness of the pharmacological treatment, identify and report drug-related issues, and provide evidence-based recommendations for the management of medication errors. When the pharmacist’s recommendations were implemented by prescribing physicians, approximately half of medication errors were intercepted before reaching the patient, resulting in fewer preventable adverse drug events.
Huang C-H, Umegaki H, Watanabe Y, et al. PLOS ONE. 2019;14:e0211947.
Various tools for identifying potentially inappropriate medications (PIMs) have been developed. This 5-year prospective cohort study of 196 elderly patients receiving home-based medical services in Japan compared the use of two tools for identifying PIMs, the American Geriatrics Society’s Beers Criteria and the relatively new Screening Tool for Older Person’s Appropriate Prescriptions for Japanese (STOPP-J), to determine the impact of PIMs on hospitalization and mortality rates. PIMs categorized by STOPP-J were associated with hospitalization and mortality, whereas Beers Criteria PIMs were associated with hospitalization only after excluding proton pump inhibitors.
Abdallah W, Johnson C, Nitzl C, et al. J Health Organ Manag. 2019;33:695-713.
Organizations are encouraged to learn from failure. The authors surveyed hospital pharmacists to explore how organizational learnings relates to safety culture and found that the strongest contributors to safety culture were organizations prioritizing and supporting training and education.
Ardenne M, Reitnauer PG. Arzneimittel-Forschung. 1975;25:1369-79.
This special issue reviews research initiatives exploring persistent challenges associated with the prescription drug misuse epidemic and strategies to monitor and reduce its persistence. Topics covered include the role of the pharmacist in addressing opioid misuse, physician–pharmacist collaboration to improve pain management, and community pharmacy monitoring of opioid dispensing.
Fahrni ML, Azmy MT, Usir E, et al. PLoS One. 2019;14:e0219898.
In this prospective study involving 301 older patients admitted to 3 hospitals, researchers used the STOPP and START criteria to identify inappropriate prescribing and adverse drug events. Inappropriate prescribing was detected in 59% of patients and potentially inappropriate medications in 35% of patients. The use of inappropriate medications was associated with an increased odds of an adverse drug event.

Chui MA, Pohjanoksa-Mäntylä M, Snyder ME, eds. Res Social Adm Pharm. 2019;15(7):811-906.

Medication safety is a worldwide challenge. This special issue discusses factors affecting the reliability of the ordering, dispensing, and administration of medications across a range of environments. Articles cover topics such as the need to deepen understanding of safety in community pharmacies, the use of smart pumps for high-alert medications, and the international effort to reduce medication-related harm.
Tasai S, Kumpat N, Dilokthornsakul P, et al. J Patient Saf. 2021;17:290-298.
Polypharmacy among older patients can increase the risk of adverse drug events. In this meta-analysis, researchers found that medication reviews performed by community pharmacists among older patients with polypharmacy reduced the risk of emergency department visits.
Hsu K-Y, DeLaurentis P, Bitan Y, et al. J Patient Saf. 2019;15:e8-e14.
Smart infusion pumps store drug safety information, but this data must be periodically updated. This study demonstrated significant delays in updating the drug information for smart infusion pumps. These delays resulted in failure to alert for two high-risk medication cases, but neither case led to patient harm.
Rahimi R, Kazemi A, Moghaddasi H, et al. Chemotherapy (Los Angel). 2018;63:162-171.
Computerized provider order entry (CPOE) is an effective tool for reducing chemotherapy medication errors. This systematic review of CPOE and clinical decision support systems for chemotherapy administration revealed a recent proliferation in the scope and complexity of both types of electronic tools. A recent WebM&M commentary examines how to prevent and respond to catastrophic chemotherapy errors.
Hasan SS, Thiruchelvam K, Kow CS, et al. Expert Rev Pharmacoecon Outcomes Res. 2017;17:431-439.
Pharmacist oversight of medication prescribing is an established safety strategy. This review explores the impact of pharmacists on reducing inappropriate polypharmacy in aged care facilities and the cost-effectiveness of this risk management strategy to substantiate the value of the practice.
Suzuki S, Chan A, Nomura H, et al. J Oncol Pract. 2017;23:18-25.
Chemotherapy is known to be a high-risk treatment that requires specific safety protocols. This study found that pharmacy checks of physician chemotherapy orders entered via computer order entry do uncover errors. The authors conclude that electronic prescribing is not sufficient to ensure safe chemotherapy prescription and recommend maintaining the role of oncology pharmacists.
Hsu C-C, Chou C-Y, Chou C-L, et al. PLoS One. 2014;9:e114359.
Clinicians may prescribe split pills for many different reasons, including dosing flexibility and patient affordability; however, this practice presents potential hazards. Splitting medications that are formulated to be extended-release or enteric-coated can lead to possibly dangerous changes in the drug's functionality. This study discusses the introduction of a clinical decision support warning that created a "hard stop" for any time an outpatient clinician attempted to prescribe a split pill for these special formulation medications. The study site was an academic medical center in Taiwan that performs more than 2.5 million ambulatory visits per year. The intervention resulted in a sharp decline in inappropriate medication splitting from a rate of approximately 0.61% to below 0.2%, where it has remained for at least 10 consecutive months. The use of a hard stop order can be controversial, as this method has resulted in unintended consequences in the past. A prior AHRQ WebM&M perspective discussed some of the tensions related to implementing medication decision support systems.
Khoo AL, Teng M, Lim BP, et al. Jt Comm J Qual Patient Saf. 2013;39:205-212.
This study involved nurses, physicians, and pharmacists in a collaborative process to design and implement a high-alert medication list at six Singaporean hospitals. Multiple interventions were implemented to improve safety of these medications, resulting in a significant reduction in adverse drug events.
Ostini R, Jackson C, Hegney D, et al. Med Care. 2011;49:24-36.
Clinicians often must have patients discontinue taking inappropriate or potentially harmful medications, in order to minimize adverse effects or eliminate drug–drug interactions. This systematic review found several potentially effective strategies for withdrawing such prescriptions.