Medication Errors in Psychiatry

Abstract

Medication errors are among the most common medical errors and cause significant morbidity and in some cases mortality. The objective of this article is to review the literature on medication errors in psychiatry. We completed a comprehensive search of both peer- and non-peer-reviewed articles that investigated medication errors in psychiatry. Our primary focus was to examine patient-, provider- and system-related factors that contributed to medication errors. Due to differences in research design and denominators used to determine error rates, the reported prevalence rates of medication errors in psychiatry vary widely. Patient-related factors identified as contributing to medication errors included non-adherence to medication, failure of patients to inform their various care providers about the medications they are taking and symptoms of psychiatric illnesses. Provider-related factors identified as contributing to medication errors were also identified and included clinical practices associated with prescribing, transcription, dispensing, administration and monitoring. Finally, the healthcare system also has a major role to play in reducing medication errors by ensuring seamless continuity of care, mandating medication reconciliation programmes, ensuring adequate clinical pharmacy services and supporting a nonpunitive medication error reporting system. Although the literature raises awareness of these specific contributing factors, there is still a great need for more systematic evaluations of the problem including root cause analysis. Medication errors in psychiatry have been studied almost exclusively in the inpatient setting and thus little is known about the incidence and significance in outpatient and community settings.

The epidemiology of adverse drug events and medication errors among psychiatric inpatients in Japan: the JADE study

“…Previous studies, however, have noted the complexities of identifying ADEs and medication errors in psychiatric settings because it is difficult to distinguish ADEs caused by drugs from symptoms related to mental disorders; in addition, it can be difficult to define medication errors in these settings, as psychiatric pharmacotherapy often deviates from standard treatment [9, 10]. In fact, there have been notably few comprehensive studies on this topic, especially regarding ADEs [7, 11–13].…”

Quality Use of Medicines – medication safety issues in naming; look-alike, sound-alike medicine names

“…Medication errors are considered among the most common medical errors [1,2] and have been noted to be of particular concern in paediatric medicine, [3] obstetrics and gynaecology, [4] anaesthesiology [5] and psychiatry. [2] For example, approximately half of the iatrogenic complications that occur in neonatal intensive-care settings are related to medication errors.…”

“…Medication errors are considered among the most common medical errors [1,2] and have been noted to be of particular concern in paediatric medicine, [3] obstetrics and gynaecology, [4] anaesthesiology [5] and psychiatry. [2] For example, approximately half of the iatrogenic complications that occur in neonatal intensive-care settings are related to medication errors. [6] Broadly speaking, medication errors can be characterised as errors in the prescribing (including dose calculations), supply (dispensing) or administration of medicines, which include the elements of drug ordering, transcribing, communication, product labelling, packaging and nomenclature, compounding, dispensing, distribution, administering, monitoring, education and use.…”

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals

“…Although medication discrepancies occurring at the primary–secondary care interface have been well characterized for general hospitals, less is known about the prevalence and nature of medication and clerical discrepancies occurring at care transfer to and from mental health hospitals . Recent studies have begun to characterize medicines‐related risk on mental health hospital admission in the UK; however, the available evidence for discharge communications remains more limited.…”