Purpose To review and analyse medication errors related to clozapine, an atypical antipsychotic, that were reported to the National Reporting and Learning System (NRLS). Methods Following extraction of one year of clozapine related errors from the NRLS, a qualitative analysis (thematic analysis and re‐classification) and quantitative analysis was performed. An incident was considered a clozapine error if there was a failure in its medication process (i.e. an error in the prescribing, dispensing, preparing, administering, monitoring or advising of clozapine). Results “Issues with stock/supply/ordering” was the most common theme derived from the qualitative thematic analysis (n = 338), followed by wrong dose/strength/frequency (n = 221) and medication omissions (n = 202). Most errors occurred in the “administration/supply” medication stage. Over half of reported clozapine incidents involved people 26 to 55 years old (n = 830) and 82% of errors were reported by mental health services (n = 1270). Only 1.5% of reports were classed as moderate/severe harm. Conclusion Issues with availability, stock, and supply were found to be the most common causes. This usually entailed a lack of stock to fulfil a patient's dose/supply. Such incidents could potentially be reduced by improved management of the supply process, and liaison between pharmacy and clinical staff. The implementation of emergency drug cupboards at the discretion of an on‐call pharmacist may prove to be a preventative measure for such errors. Despite the potential adverse effects associated with clozapine, very few incidents led to moderate/severe harm. Encouragement of NRLS reporting is recommended for incidents of all degrees of harm.

AimTo assess the monitoring of antipsychotic medication in secondary care services in accordance with The National Institute for Health and Care Excellence (NICE) guidelines1.BackgroundRecent NICE guidelines on Psychosis and schizophrenia in adults1state that the secondary care team should monitor patients' physical health and the effects of antipsychotic medication for at least 12 months or until the person's condition has stabilised, and thereafter consider shared care with Primary care.MethodsThe electronic database generated a sample of 30 new service users attending a local community team in Solihull, UK who were initiated on antipsychotics between January 2012 and March 2013. We analysed electronic documentation according to an audit tool developed by our Trust Clinical Pharmacist, based on NICE guidelines.ResultsResults showed that 83% of patients were monitored for over 12 months or until stabilised. Other documentations included response to treatment and side effects of treatment (96.7%), emergence of movement disorders (36.7%), adherence to treatment (86.7%) and physical health (90%).ConclusionsMost patients were followed up for their mental health. Documentation and/or specific monitoring of physical health parameters as detailed in the guidelines remained less than 30%. Similarly, the emergence of movement disorders was infrequently recorded. Training is required to improve the understanding of the importance of monitoring of physical health in individuals with psychosis or schizophrenia, especially those taking antipsychotics. Re-audit to follow.[1] NICE. NICE guideline on Psychosis and schizophrenia in adults: treatment and management, CG178: February 2014. .

Creating Mental Wealth Creating Mental Wealth was the theme of Primhe's Annual Conference held jointly with Wales Mental Health in Primary Care Network (WaMHinPC) in Cardiff in April. Matthew Elswood, a Mental Health Pharmacist from Milton Keynes, reports on some of the highlights. What value health care? GP, writer and broadcaster, Phil Hammond, who chaired Primhe's annual conference, offers these observations on the meeting. Copyright © 2008 Wiley Interface Ltd