The medication process in a psychiatric hospital: are errors a potential threat to patient safety?

Abstract

Purpose

To investigate the frequency, type, and potential severity of errors in several stages of the medication process in an inpatient psychiatric setting.

Methods

A cross-sectional study using three methods for detecting errors: (1) direct observation; (2) unannounced control visits in the wards collecting dispensed drugs; and (3) chart reviews. All errors, except errors in discharge summaries, were assessed for potential consequences by two clinical pharmacologists.

Setting

Three psychiatric wards with adult patients at Aalborg University Hospital, Denmark, from January 2010–April 2010.

The observational unit

The individual handling of medication (prescribing, dispensing, and administering).

Results

In total, 189 errors were detected in 1,082 opportunities for error (17%) of which 84/998 (8%) were assessed as potentially harmful. The frequency of errors was: prescribing, 10/189 (5%); dispensing, 18/189 (10%); administration, 142/189 (75%); and discharge summaries, 19/189 (10%). The most common errors were omission of pro re nata dosing regime in computerized physician order entry, omission of dose, lack of identity control, and omission of drug.

Conclusion

Errors throughout the medication process are common in psychiatric wards to an extent which resembles error rates in somatic care. Despite a substantial proportion of errors with potential to harm patients, very few errors were considered potentially fatal. Medical staff needs greater awareness of medication safety and guidelines related to the medication process. Many errors in this study might potentially be prevented by nursing staff when handling medication and observing patients for effect and side effects of medication. The nurses’ role in psychiatric medication safety should be further explored as nurses appear to be in the unique position to intercept errors before they reach the patient.

Keywords:

• medication safety
• mental health disorders
• medication errors
• psychiatry

Supplementary tables

Table S1 Criteria and definitions for error types

Table S2 Definition of potential clinical consequences

Reference

• LisbyMNielsenLPMainzJErrors in the medication process: frequency, type, and potential clinical consequencesInt J Qual Health Care2005171152215668306
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Disclosure

The authors report no conflicts of interest in this work.