Medication errors still represent a momentous unmet need in society. This is even well after so many calls for action by various professional organizations, state boards of pharmacy, federal government agencies, think tanks, academic and practice leaders, and others.

Hong et al discuss this issue is a poignant commentary.¹ They describe the prevalence of medication errors as having placed a serious medical and economic burden on the U.S. healthcare system. Government health agencies and non-profit organizations in the U.S., such as the Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine (IOM), and the Joint Commission have undertaken initiatives intended to reduce medication errors, with at least some progress in inpatient settings. They assert, however, that there have been fewer advances in the community setting, and that there has been limited information on community pharmacies’ involvement in reducing and preventing medication errors. Most published studies on medication errors in community pharmacy settings are cross-sectional in design and often confined in just one or a few pharmacies in a single city or small geographic region. To reduce medication errors, improvement strategies such as transparency and bi-directional communication between pharmacists and patients are needed. To improve transparency, the authors recommend that these questions be addressed by community pharmacy corporations: 1. How does your corporation manage medication errors? 2. Does your corporation collect all medication error data to review systematically? 3. What are some strategies that your corporation utilizes to reduce medication errors? 4. Would your corporation be willing to share its data related to medication errors publicly in an effort to facilitate research in this area, which may promote patient safety in the community setting? The authors also remind us that pharmacists are required by law to counsel patients, and research has shown that counseling can assist with detecting medication errors. By improving transparency in quality assurance processes and promoting patient engagement to improve patient safety, community pharmacies have the potential to play a more active role in reducing medication errors and safeguarding patients from harm.

The fact that counseling helps detect errors in addition to promoting adherence says much for this practice. Pharmacy managers can promote cultures of safety, patient service, and transparency through simple messaging and feedback, readily available company mission/values, reinforcement of patient-centric practice, proper workflow design, and initiating meaningful quality assurance processes aimed to minimize errors.

Additional information about Ensuring Quality in Pharmacy Operations and Risk Management in Contemporary Pharmacy Practice can be found in Pharmacy Management: Essentials for All Practice Settings, 5e. If you or your institution subscribes to AccessPharmacy, use or create your MyAccess Profile to sign-in to Pharmacy Management: Essentials for All Practice Settings, 5e. If your institution does not provide access, ask your medical librarian about subscribing.

¹Hong K, Hong YD, Cooke CE. Medication errors in community pharmacy: The need for commitment, transparency, and research. Res Social Adm Pharm. https://doi.org/10.1016/j.sapharm.2018.11.014