Adverse drug events and medication errors in psychiatry: methodological issues regarding identification and classification

Potential Risk Factors of Drug-Related Problems in Hospital-Based Mental Health Units: A Systematic Review

INTRODUCTION

Reducing the occurrence of drug-related problems is a global health concern. In mental health hospitals, drug-related problems are common, leading to patient harm, and therefore understanding their potential risk factors is key for guiding future interventions designed to minimise their frequency.

OBJECTIVE

The aim of this systematic review was to explore the potential risk factors of drug-related problems in mental health inpatient units.

METHODS

Six databases were searched between 2000 and 2021 to identify studies that investigated the potential risk factors of drug-related problems in adults hospitalised in mental health inpatient units. Data extraction was performed by two authors independently and Allan and Barker's criteria were used for study quality assessment. Studies were categorised based on drug-related problem types and potential risk factors were stratified as patient, medication, and hospital related.

RESULTS

A total of 22 studies were included. Studies mostly originated in Europe (n = 19/22, 86.4%), and used a multivariable logistic regression to identify potential risk factors (n = 13, 59%). Frequently investigated factors were patient age (n = 14/22), sex (n = 14/22) and the number of prescribed medications (n = 14/22). Of these, increasing the number of prescribed medications was the only factor consistently reported to be significantly associated with the occurrence of most types of drug-related problems (n = 11/14).

CONCLUSIONS

A variety of patient, medication and hospital-related potential risk factors of drug-related problems in mental health inpatient units were identified. These factors could guide the development of interventions to reduce drug-related problems such as pharmaceutical screening tools to identify high-risk patients for timely interventions. Future studies could test a wider range of possible factors associated with drug-related problems using standardised approaches.

CLINICAL TRIAL REGISTRATION

PROSPERO: CRD42021279946.

Drug-related problems and associated factors among adult psychiatric inpatients in Northwest Ethiopia: Multicenter cross-sectional study

Objective:

To determine the prevalence of drug-related problems and the factors influencing them among adult psychiatric inpatients.

Methods:

A multi-centre cross-sectional observational study was conducted from April to July 2021 at five randomly selected hospitals in Northwest Ethiopia. A total of 325 consecutively sampled patients participated in the study. Clinical pharmacists assessed the drug-related problems based on clinical judgement supported by updated evidence-based disease guidelines. We used the Medscape drug-interactions checker to check drug-to-drug interactions. The results were summarised using descriptive statistics, including frequency, mean, and standard deviation. For each variable, an odds ratio with a 95% confidence interval was calculated, as well as the related p-value. The value of p ⩽ 0.05 was considered statistically significant.

Results:

From the total number of 325 study participants, more than half of them (52.9%) were females, and the mean age ± (standard deviation) was 30.8 ± 11.3 years. At least one drug-related problem was recorded by 60.9% to 95% confidence interval (55.7–65.8) of study participants, with a mean of 0.6 ± 0.49 per patient. Additional drug therapy was the most common drug-related problem (22.8%) followed by non-adherence to medicine (20.6%) and adverse drug reactions (11%), respectively. Factors independent associated with drug-related problems were rural residence (adjusted odds ratio = 1.96, 95% confidence interval: 1.01–2.84, p-value = 0.046), self-employed (adjusted odds ratio = 6.0, 95% confidence interval: 1.0–36.9, p-value = 0.035) and alcohol drinkers (adjusted odds ratio = 6.40, 95% confidence interval: 1.12–37.5, p-value = 0.034).

Conclusion:

The prevalence of drug-related problems among adult psychiatric patients admitted to psychiatric wards was high. Healthcare providers give more attention to tackling these problems. Being a rural resident, self-employed, and alcohol drinkers were associated with drug-related problems.

Biometric palm vein authentication of psychiatric patients for reducing in-hospital medication errors: a pre-post observational study

OBJECTIVES

This study aimed to evaluate a biometric palm vein authentication system to prevent medication administration errors in psychiatric hospitals.

DESIGN

This is a pre-post observational study.

SETTING

Conventionally, the medication was distributed after a double check. We developed and introduced a new medication administration cart in two psychiatric hospitals in Japan, in which each patient-specific drug box had to be electronically opened only by palm vein authentication.

PARTICIPANTS

A total of 3444 and 3523 patients were present 18 months before and after introducing the cart, respectively. Of the 212 nurses recruited, 28 were excluded due to a lack of experience with the conventional medication administration system and incomplete questionnaires.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the efficacy of this system by comparing the incidence of medication administration errors before and after introducing the cart. The secondary outcome was a survey regarding nurses' attitudes toward this system.

RESULTS

After introduction of the new system, the number of medication errors due to misidentification of persons relative to the total number of admitted patients was significantly reduced from 6/3444 to 2/3523 (p<0.0001). Among 184 nurses, 182 responded that anxiety regarding administration errors was either reduced or unchanged using this system. Male nurses reported a greater increase in work burden than female nurses (OR=3.11, 95% CI=1.44 to 6.72). Nurses working in chronic care wards reported greater time pressure than nurses working in emergency wards (OR=3.33, 95% CI=1.16 to 9.57). Nurses working in dementia care wards reported a greater patient care burden than nurses working in emergency wards (OR=5.67, 95% CI=1.22 to 26.27).

CONCLUSIONS

This new system might have potential for reducing the patient misidentification risk during medication without increasing the anxiety experienced by nurses concerning administration errors. However, system usability and efficiency must be improved to reduce additional work burden, time pressure and patient care burden.

Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review

OBJECTIVES

The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm.

METHOD

A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy.

RESULTS

The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization.

CONCLUSIONS

The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.

Development of a Trigger Tool to Identify Adverse Events and Harm in a Neuropsychiatry Setting

BACKGROUND OBJECTIVES

Adverse drug events (ADEs) present the greatest risk of harm to patients in hospitals, especially those receiving neuropsychiatric treatment. The objective of the present record-based study was to test the appropriateness of the neuropsychiatry trigger tool (NPTT) to identify and measure harm due to adverse events (AEs).

METHODS

A total of 1324 clinical case notes of discharged patients from 2017 to 2018 with a hospital stay >24 hours to <70 days were examined.

RESULTS

One hundred forty-four (10.88%) patients experienced 166 AEs. A total of 854 triggers (range, 1-12 triggers per patient) were identified in 296 (22.36%) and 39 (2.94%) patients presented with triggers at admission. The overall AE rate per 1000 patient days was 12.73 (intensive care unit, 21; inpatient department, 11.54). Triggers at admission were altered sensorium and abnormal behavior followed by headache, ataxia, and aspiration pneumonia. A small number of triggers accounted for most AEs (laxative, rising liver function test (LFT), hypokalemia, hyponatremia, health care-associated infections, intubation, abnormal behavior/sensorium, hepatic encephalopathy, antiemetics), although type of AE reported differed by level of care. Most AEs caused minor harm, and relatively fewer patients experienced temporary harm requiring intervention (110; 8.29%), permanent harm (45; 3.39%), harm requiring initial/prolonged hospitalization (10; 0.75%), interventions to sustain life (24; 1.81%), and death (109; 8%). The higher the number of AEs, the longer was the length of stay (average increased from 9.32 to 17.33 days). The NPTT identified 30 times more AEs compared with 5 AEs reported by voluntary method. Medication-related ADEs were found in 130 (90%) of 144 patients who experienced AEs. Antitubercular drugs caused most ameliorable AEs (visual disturbance, drug-induced vomiting, deranged LFT, constipation). Care is needed in attributing harm because some triggers (abnormal sensorium/behavior, intubation, headache/dizziness, laxatives) may overlap with neurological illnesses (cerebrovascular accident [CVA]/meningitis/stroke). If the triggers are identified early, harm/discomfort to the patients can be reduced. The NPTT can be used in patient safety improvement projects. Harm occurred in 296 (22.28%) patients (temporary, 120 [9%]; permanent, 178 [13%]). Adverse events prolonged hospital stay (14.29 days) compared with 9.32 days in patients without AEs.

CONCLUSIONS

A higher number of triggers per patient (≥5), trigger nature (intubation, cardiac arrest/shock), or the presenting illness (CVA/neuroinfections/status epilepticus/prolonged seizures) were correlated with the highest harm, that is, death. Because some triggers (abnormal sensorium/behavior, headache/dizziness, laxatives, intubation) may overlap with neurological illness (CVA/meningitis/stroke), care is needed in attributing harm. The NPTT identified 30 times more AEs compared with 5 AEs reported by voluntary method. Antitubercular drugs caused ameliorable AEs (visual disturbance, drug-induced vomiting, deranged LFT, constipation) and, if identified early, can reduce harm/discomfort to the patients.

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD)

Background

Most patients with mental illness are managed in primary care, yet there is a lack of data exploring potential prescribing safety issues in this setting for this population.

Objectives

Examine the prevalence of, between-practice variation in, and patient and practice-level risk factors for, 18 mental health-related potentially hazardous prescribing indicators and four inadequate medication monitoring indicators in UK primary care.

Method

Cross-sectional analyses of routinely collected electronic health records from 361 practices contributing to Clinical Practice Research Datalink GOLD database. The proportion of patients ‘at risk’ (based on an existing diagnosis, medication, age and/or sex) triggering each indicator and composite indicator was calculated. To examine between-practice variation, intraclass correlation coefficient (ICC) and median OR (MOR) were estimated using two-level logistic regression models. The relationship between patient and practice characteristics and risk of triggering composites including 16 of the 18 prescribing indicators and four monitoring indicators were assessed using multilevel logistic regression.

Results

9.4% of patients ‘at risk’ (151 469 of 1 611 129) triggered at least one potentially hazardous prescribing indicator; between practices this ranged from 3.2% to 24.1% (ICC 0.03, MOR 1.22). For inadequate monitoring, 90.2% of patients ‘at risk’ (38 671 of 42 879) triggered at least one indicator; between practices this ranged from 33.3% to 100% (ICC 0.26, MOR 2.86). Patients aged 35–44, females and those receiving more than 10 repeat prescriptions were at greatest risk of triggering a prescribing indicator. Patients aged less than 25, females and those with one or no repeat prescription were at greatest risk of triggering a monitoring indicator.

Conclusion

Potentially hazardous prescribing and inadequate medication monitoring commonly affect patients with mental illness in primary care, with marked between-practice variation for some indicators. These findings support health providers to identify improvement targets and inform development of improvement efforts to reduce medication-related harm.

Prevalence, Nature, Severity and Preventability of Adverse Drug Events in Mental Health Settings: Findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) Study

INTRODUCTION

Adverse drug events (ADEs) constitute a significant problem in hospitals worldwide. However, little is known about their burden in mental health hospitals.

OBJECTIVE

The objective of this study was to determine the prevalence, nature, severity and preventability of ADEs across three mental health trusts in England.

METHODS

Trained clinical pharmacists retrospectively screened randomly sampled medical records to identify ADEs. An expert panel assessed all suspected ADEs to determine their causality, preventability and severity. Multivariable regression analysis (adjusted for clustering between hospitals) examined risk factors associated with ADEs.

RESULTS

In total, 227 patient admissions comprising 10,164 patient-days of follow-up were included in the study. The adjusted rate of confirmed ADEs was 12.6 (95% confidence interval [CI] 5.6-26.0) per 100 admissions and 2.6 (95% CI 1.0-6.9) per 1000 patient-days, with almost a fifth of these ADEs judged as preventable 19.1% (n = 9/47). The majority of ADEs were of at least moderate clinical severity (29/47; 61.7%), and medicines from the central nervous system class were most commonly implicated in ADEs (45/47; 95.7%) including antipsychotics (31/45; 68.8%) and antidepressants (7/45; 15.5%). Patients with a hospital stay of more than 30 days (odds ratio 16.58, 95% CI 3.77-72.85) and patients with a stay of 8-30 days (odds ratio 5.32, 95% CI 1.22-23.07) were more likely to experience an ADE compared with patients with a stay of 1-7 days.

CONCLUSIONS

Adverse drug events in National Health Service mental health hospitals pose an important threat to patient safety. Targets for remedial interventions have been suggested for further exploration to improve patient safety in this setting.

Development of prescribing safety indicators related to mental health disorders and medications: Modified e-Delphi study

AIM

To develop a set of prescribing safety indicators related to mental health disorders and medications, and to estimate the risk of harm associated with each indicator.

METHOD

A modified two-stage electronic Delphi. The first stage consisted of two rounds in which 31 experts rated their agreement with a set of 101 potential mental health related prescribing safety indicators using a five-point scale and given the opportunity to suggest other indicators. Indicators that achieved 80% agreement were accepted. The second stage comprised a single round in which 29 members estimated the risk of harm for each accepted indicator by assessing the occurrence likelihood and outcome severity using two five-point scales. Indicators were considered high or extreme risk when at least 80% of participants rated each indicator as high or extreme.

RESULTS

Seventy-five indicators were accepted in the first stage. Following the second stage, 42 (56%) were considered to be high or extreme risk for patient care. The 42 indicators comprised different types of hazardous prescribing, including drug-disease interactions (n = 12), drug-drug interactions (n = 9), inadequate monitoring (n = 5), inappropriate duration (n = 4), inappropriate dose (n = 4), omissions (n = 4), potentially inappropriate medications (n = 3) and polypharmacy (n = 1). These indicators also covered different mental health related medication classes, including antipsychotics (n = 14), mood stabilisers (n = 8), antidepressants (n = 6), sedative, hypnotics and anxiolytics (n = 6), anticholinergic (n = 6) and nonspecific psychotropics (n = 2).

CONCLUSION

This study has developed the first suite of prescribing safety indicators related to mental health disorders and medications, which could inform the development of future safety improvement initiatives and interventional studies.

European Psychiatric Association (EPA) guidance on quality assurance in mental healthcare

Purpose:

To advance the quality of mental healthcare in Europe by developing guidance on implementing quality assurance.

Methods:

We performed a systematic literature search on quality assurance in mental healthcare and the 522 retrieved documents were evaluated by two independent reviewers (B.J. and J.Z.). Based on these evaluations, evidence tables were generated. As it was found that these did not cover all areas of mental healthcare, supplementary hand searches were performed for selected additional areas. Based on these findings, fifteen graded recommendations were developed and consented by the authors. Review by the EPA Guidance Committee and EPA Board led to two additional recommendations (on immigrant mental healthcare and parity of mental and physical healthcare funding).

Results:

Although quality assurance (measures to keep a certain degree of quality), quality control and monitoring (applying quality indicators to the current degree of quality), and quality management (coordinated measures and activities with regard to quality) are conceptually distinct, in practice they are frequently used as if identical and hardly separable. There is a dearth of controlled trials addressing ways to optimize quality assurance in mental healthcare. Altogether, seventeen recommendations were developed addressing a range of aspects of quality assurance in mental healthcare, which appear usable across Europe. These were divided into recommendations about structures, processes and outcomes. Each recommendation was assigned to a hierarchical level of analysis (macro-, meso- and micro-level).

Discussion:

There was a lack of evidence retrievable by a systematic literature search about quality assurance of mental healthcare. Therefore, only after further topics and search had been added it was possible to develop recommendations with mostly medium evidence levels.

Conclusion:

Evidence-based graded recommendations for quality assurance in mental healthcare were developed which should next be implemented and evaluated for feasibility and validity in some European countries. Due to the small evidence base identified corresponding to the practical obscurity of the concept and methods, a European research initiative is called for by the stakeholders represented in this Guidance to improve the educational, methodological and empirical basis for a future broad implementation of measures for quality assurance in European mental healthcare.

Identifying potential prescribing safety indicators related to mental health disorders and medications: A systematic review

BACKGROUND

Prescribing errors and medication related harm may be common in patients with mental illness. However, there has been limited research focusing on the development and application of prescribing safety indicators (PSIs) for this population.

OBJECTIVE

Identify potential PSIs related to mental health (MH) medications and conditions.

METHODS

Seven electronic databases were searched (from 1990 to February 2019), including the bibliographies of included studies and of relevant review articles. Studies that developed, validated or updated a set of explicit medication-specific indicators or criteria that measured prescribing safety or quality were included, irrespective of whether they contained MH indicators or not. Studies were screened to extract all MH related indicators before two MH clinical pharmacists screened them to select potential PSIs based on established criteria. All indicators were categorised into prescribing problems and medication categories.

RESULTS

79 unique studies were included, 70 of which contained at least one MH related indicator. No studies were identified that focused on development of PSIs for patients with mental illness. A total of 1386 MH indicators were identified (average 20 (SD = 25.1) per study); 245 of these were considered potential PSIs. Among PSIs the most common prescribing problem was 'Potentially inappropriate prescribing considering diagnoses or conditions' (n = 91, 37.1%) and the lowest was 'omission' (n = 5, 2.0%). 'Antidepressant' was the most common PSI medication category (n = 85, 34.7%).

CONCLUSION

This is the first systematic review to identify a comprehensive list of MH related potential PSIs. This list should undergo further validation and could be used as a foundation for the development of new suites of PSIs applicable to patients with mental illness.

Drug-drug interactions and pharmacists' interventions among psychiatric patients in outpatient clinics of a teaching hospital in Saudi Arabia

Background

Lack of recognition of labeled drug-drug interactions (DDIs) is a type of medication error of particular relevance to the treatment of psychiatric patients. Pharmacists are in a position to detect and address potential DDIs.

Objective

This study aimed to explore pharmacists' role in the identification and management of DDIs among psychiatric patients in psychiatric outpatient clinics of a university-affiliated tertiary care hospital in Riyadh, Saudi Arabia.

Method

This study was a retrospective, cross-sectional medical chart review of patients visiting outpatient psychiatric clinics. It utilized medical records of patients who were taking any psychotropic medications and were prescribed at least one additional drug. The hospital Computerized Physician Order Entry system was used to identify DDIs and determine the pharmacists' interventions. The Beers criteria were applied to detect inappropriate prescribing among older patients.

Results

On average, the pharmacists intervened in 12 out of 213 (5.6%) cases of major or moderate DDIs. Older age, higher number of prescription medications, the severity of DDIs, and the utilization of lithium and anticoagulants were positively associated with the pharmacist undertaking an action.

Conclusion

Future studies should explore the prevalence rate of harmful DDIs among psychiatric patients on a large scale and examine the effectiveness of different pharmacy policies in the detection and management of DDIs.

Safety culture: perception of health professionals in a mental hospital

OBJECTIVE

To evaluate the culture of patient safety in a mental health service.

METHOD

Cross-sectional study conducted with health professionals in a mental hospital, by applying the Safety Attitudes Questionnaire (SAQ). Descriptive and inferential analyses were performed.

RESULTS

One-hundred and three professionals participated in the study, with female predominance (64.1%) and time of performance equal to or greater than 21 years (32.4%). The nursing professionals of technical level and with statutory work regime were the most participative, 54.4% and 52% respectively. The total score was 69 points. The domain that reached the highest score was Job satisfaction (80 points) and the lowest was Working conditions (57 points). The statutory professionals and those with longer professional experience obtained better scores in the perception of safety culture.

CONCLUSION

The result of safety culture was below the recommended, indicating the need for strengthening this construct in mental health hospitals.

Antidepressant and antipsychotic medication errors reported to United States poison control centers

PURPOSE

To investigate unintentional therapeutic medication errors associated with antidepressant and antipsychotic medications in the United States and expand current knowledge on the types of errors commonly associated with these medications.

METHODS

A retrospective analysis of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications was conducted using data from the National Poison Data System.

RESULTS

From 2000 to 2012, poison control centers received 207 670 calls reporting unintentional therapeutic errors associated with antidepressant or antipsychotic medications that occurred outside of a health care facility, averaging 15 975 errors annually. The rate of antidepressant-related errors increased by 50.6% from 2000 to 2004, decreased by 6.5% from 2004 to 2006, and then increased 13.0% from 2006 to 2012. The rate of errors related to antipsychotic medications increased by 99.7% from 2000 to 2004 and then increased by 8.8% from 2004 to 2012. Overall, 70.1% of reported errors occurred among adults, and 59.3% were among females. The medications most frequently associated with errors were selective serotonin reuptake inhibitors (30.3%), atypical antipsychotics (24.1%), and other types of antidepressants (21.5%). Most medication errors took place when an individual inadvertently took or was given a medication twice (41.0%), inadvertently took someone else's medication (15.6%), or took the wrong medication (15.6%).

CONCLUSIONS

This study provides a comprehensive overview of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications. The frequency and rate of these errors increased significantly from 2000 to 2012. Given that use of these medications is increasing in the US, this study provides important information about the epidemiology of the associated medication errors.

Monitoring of patients treated with lithium for bipolar disorder: an international survey

Background

Adequate monitoring of patients using lithium is needed for optimal dosing and for early identification of patients with (potential) ADEs. The objective was to internationally assess how health care professionals monitor patients treated with lithium for bipolar disorder.

Methods

Using networks of various professional organizations, an anonymous online survey was conducted among health care professionals prescribing lithium. Target lithium serum levels and frequency of monitoring was assessed together with monitoring of physical and laboratory parameters. Reasons to and not to monitor and use of guidelines and institutional protocols, and local monitoring systems were investigated.

Results

The survey was completed by 117 health care professionals incorporating responses from twenty-four countries. All prescribers reported to monitor lithium serum levels on a regular basis, with varying target ranges. Almost all (> 97%) monitored thyroid and renal function before start and during maintenance treatment. Reported monitoring of other laboratory and physical parameters was variable. The majority of respondents (74%) used guidelines or institutional protocols for monitoring. In general, the prescriber was responsible for monitoring, had to request every monitoring parameter separately and only a minority of patients was automatically invited.

Conclusions

Lithium serum levels, renal and thyroid function were monitored by (almost) all physicians. However, there was considerable variation in other monitoring parameters. Our results help to understand why prescribers of lithium monitor patients and what their main reasons are not to monitor patients using lithium.

Electronic supplementary material

The online version of this article (10.1186/s40345-018-0120-1) contains supplementary material, which is available to authorized users.

A proposal for a psychopharmacology-pharmacotherapy catalogue of learning objectives and a curriculum in Europe

Objectives Post-graduate training for specialisation in psychiatry and psychotherapy is part of a 4-6-year programme. This paper aims to inform on the general situation of teaching and training of psychopharmacology-psychopharmacotherapy in Europe. It presents the need for a psychopharmacotherapy education in psychiatric training programmes. Arguments as well as a proposal for a catalogue of learning objectives and an outline of a psychopharmacology curriculum are presented. Methods Based on their experience and on an analysis of the literature, the authors, experts in psychopharmacology-pharmacotherapy teaching, critically analyse the present situation and propose the development of a curriculum at the European level. Results Teaching programmes vary widely between European countries and, generally, teaching of psychopharmacology and pharmacotherapy does not exceed two-dozen hours. This is insufficient if one considers the central importance of psychopharmacology. A psychopharmacology-psychopharmacotherapy curriculum for the professional training of specialists in psychiatry and psychotherapy is proposed. Conclusions As the number of hours of theoretical teaching and practical training is insufficient, a catalogue of learning objectives should be established, which would then be part of a comprehensive curriculum at the European level. It could be inspired partly by those few previously proposed by other groups of authors and organisations.

Potential underreporting of medication errors in a psychiatric general hospital in Japan

The purpose of this study was to explore a pattern of underreporting within a psychiatric general hospital in Japan. All the medication errors reported online in 2010 were analysed. This research was approved by the university and the study hospital. There were 651 incidents related to medication errors. Medication error rate per 1000 patient days was 2.14 (range: 0.45-6.05). Medication error rates between two acute care wards with comparable case and staff mix differed. A low proportion of intercepted near-misses and low medication error rates around mealtime in acute care 1 were suggestive of under-reporting. Two dementia care wards with low medication error rates had no report of intercepted errors, which was also suggestive of underreporting. Ward-specific medication error rates and patterns are useful to identify wards with potential underreporting of medication error within the hospital.

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

BACKGROUND

Knowledge of the epidemiology of adverse drug events (ADEs) and medication errors in psychiatric inpatients is limited outside Western countries. The nature of ADEs and medication errors are important for improving the quality of care worldwide; therefore, we conducted the Japan Adverse Drug Events Study, a series of cohort studies at several settings in Japan.

METHODS

This report included 448 inpatients with 22,733 patient-days in a psychiatric hospital and psychiatric units at a tertiary care teaching hospital over 1 year. Four psychiatrists and two other physicians reviewed all medical charts and related documents to identify suspected incidents. The physicians later classified those incidents into ADEs, potential ADEs, medication errors, or exclusions and evaluated the severity and preventability if the incidents were events.

RESULTS

During the study period, we identified 955 ADEs and 398 medication errors (incidence: 42.0 and 17.5 per 1000 patient-days, respectively). Among ADEs, 1.4 %, 28 %, and 71 % were life-threatening, serious, and significant, respectively. Antipsychotics were associated with half of all ADEs. The incidence of medication errors was higher in medical care units than in acute and nursing care units (40.9, 15.6, and 17.4 per 1000 patient-days, respectively). The monitoring and ordering stages were the most common error stages (39 % and 34 % of all medication errors, respectively), and 76 % of medication errors with ADEs were found at the monitoring stage. Non-psychiatric drugs were three times as likely to cause ADEs with errors compared to psychiatric drugs.

CONCLUSIONS

Antipsychotic use, inadequate monitoring, and treatment of physical ailments by psychiatrists may contribute to the high incidence of medication errors and ADEs among psychiatric inpatients in Japan. Psychiatrists should be cautious in prescribing antipsychotics or unfamiliar medications for physical problems in their psychiatric patients, and should monitor patients after medication administration.

Potentially inappropriate prescriptions in patients admitted to a psychiatric hospital

Background Very little is known about the general appropriateness of prescribing for psychiatric patients. Aims To identify prevalence and types of potentially inappropriate prescribing (PIP) of psychotropic and somatic medications, to assess the severity of potential clinical consequences and to identify possible predictive factors of PIP in a sample of adult psychiatric in-patients. Methods A descriptive, cross-sectional design using medication reviews by clinical pharmacologists to identify PIP during a 3-month period. The setting was in-patient units in a psychiatric department of a Danish university hospital during a 3-month period (September 2013-November 2013). Patients medication lists (n = 207) were reviewed at the time of admission and all identified PIPs were assessed for potential consequences by clinical pharmacologists. Results There were 349 PIP identified in 1291 prescriptions. The proportion of patients found to have at least one PIP was 123/207 (59%) and the proportions of patients with at least one PIP assessed to be potentially serious or fatal was 69/207 (33%) and 24/207 (12%), respectively. Interactions between drugs 125/207 (36%) and too high doses of drugs 56/207 (16%) were the most frequent PIP. Predictive factors for PIP were polypharmacy (>5 prescriptions) and having one or more somatic diagnoses. Conclusion PIP is common in psychiatric patients and potentially fatal. Particularly polypharmacy (>5 prescriptions) and concomitant somatic illness were associated with the probability of PIP. Improving the quality of prescribing might benefit from an interprofessional approach and thus better training of physicians and nurses is needed in order to minimize PIP.

Pharmacist-Led Medication Reviews to Identify and Collaboratively Resolve Drug-Related Problems in Psychiatry - A Controlled, Clinical Trial

Aim of the study

This prospective, controlled trial aimed to assess the effect of pharmacist-led medication reviews on the medication safety of psychiatric inpatients by the resolution of Drug-Related Problems (DRP). Both the therapy appropriateness measured with the Medication Appropriateness Index (MAI) and the number of unsolved DRP per patient were chosen as primary outcome measures.

Methods

Depending on their time of admission, 269 psychiatric patients that were admitted to a psychiatric university hospital were allocated in control (09/2012-03/2013) or intervention group (05/2013-12/2013). In both groups, DRP were identified by comprehensive medication reviews by clinical pharmacists at admission, during the hospital stay, and at discharge. In the intervention group, recommendations for identified DRP were compiled by the pharmacists and discussed with the therapeutic team. In the control group, recommendations were not provided except for serious or life threatening DRP. As a primary outcome measure, the changes in therapy appropriateness from admission to discharge as well as from admission to three months after discharge (follow-up) assessed with the MAI were compared between both groups. The second primary outcome was the number of unsolved DRP per patient after completing the study protocol. The DRP type, the relevance and the potential of drugs to cause DRP were also evaluated.

Results

The intervention led to a reduced MAI score by 1.4 points per patient (95% confidence interval [CI]: 0.8–2.0) at discharge and 1.3 points (95% CI: 0.7–1.9) at follow-up compared with controls. The number of unsolved DRP in the intervention group was 1.8 (95% CI: 1.5–2.1) less than in control.

Conclusion

The pharmaceutical medication reviews with interdisciplinary discussion of identified DRP appears to be a worthy strategy to improve medication safety in psychiatry as reflected by less unsolved DRP per patient and an enhanced appropriateness of therapy. The promising results of this trial likely warrant further research that evaluates direct clinical outcomes and health-related costs.

Trial Registration

Deutsches Register Klinischer Studien (DRKS), DRKS00006358

Documentation of medication changes in inpatient clinical notes: an audit to support quality improvement

OBJECTIVE

To describe completeness and accuracy of recording medication changes in progress notes during psychiatric inpatient admissions.

METHOD

A retrospective audit of records of 54 randomly selected psychiatric admissions at a metropolitan tertiary hospital. Medication changes recorded on National Inpatient Medication Chart (NIMC) were compared to documentation in the clinical progress records and assessed for completeness against seven quality criteria.

RESULTS

With between one and 32 medication changes per admission, a total of 519 changes were recorded in NIMCs. Just over half were documented in progress notes. Psychotropic and regular medications were more frequently charted than 'other' and 'if required' medications. Documentation was seldom comprehensive. Medication name was most frequently documented; desired therapeutic effect or potential adverse effects were rarely documented. Evidence of patient involvement in, and an explicit rationale for, a change were infrequently recorded.

CONCLUSIONS

Revealing substantial gaps in communication about medication changes during psychiatric admission, this audit sheds light on a previously undescribed source of medication error, warranting attention. Further research is needed to examine barriers to best practice, to support design and implementation of quality improvement activities but in the interim, attention should be addressed to development and articulation of content and procedures for documentation.

Prevalence, nature and predictors of prescribing errors in mental health hospitals: a prospective multicentre study

OBJECTIVE

To determine the prevalence, nature and predictors of prescribing errors (PEs) in three mental health hospitals.

SETTING

Inpatient units in three National Health Service (NHS) mental health hospitals in the North West of England.

PARTICIPANTS

Trained clinical pharmacists prospectively recorded the number of PEs in newly written or omitted prescription items screened during their routine work on 10 data collection days. A multidisciplinary panel reviewed PE data using established methods to confirm (1) the presence of a PE, (2) the type of PE and (3) whether errors were clinically relevant and likely to cause harm.

PRIMARY OUTCOME MEASURES

Frequency, nature and predictors of PEs.

RESULTS

Of 4427 screened prescription items, 281 were found to have one or more PEs (error rate 6.3% (95% CI 5.6 to 7.1%)). Multivariate analysis revealed that specialty trainees (OR 1.23 (1.01 to 1.51)) and staff grade psychiatrists (OR 1.50 (1.05 to 2.13)) were more likely to make PEs when compared to foundation year (FY) one doctors, and that specialty trainees and consultant psychiatrists were twice as likely to make clinically relevant PEs (OR 2.61 (2.11 to 3.22) and 2.03 (1.66 to 2.50), respectively) compared to FY one staff. Prescription items screened during the prescription chart rewrite (OR 0.52 (0.33 to 0.82)) or at discharge (OR 0.87 (0.79 to 0.97)) were less likely to be associated with PEs than items assessed during inpatient stay, although they were more likely to be associated with clinically relevant PEs (OR 2.27 (1.72 to 2.99) and 4.23 (3.68 to 4.87), respectively). Prescription items screened at hospital admission were five times more likely (OR 5.39 (2.72 to 10.69)) to be associated with clinically relevant errors than those screened during patient stay.

CONCLUSIONS

PEs may be more common in mental health hospitals than previously reported and important targets to minimise these errors have been identified.

An expert panel assessment of comprehensive medication reviews for clients of community mental health teams

BACKGROUND

Few studies have investigated strategies to identify and resolve drug-related problems among clients of community mental health teams (CMHTs).

OBJECTIVE

The objective of this study was to evaluate the clinical impact and appropriateness of comprehensive medication reviews for clients of CMHTs.

METHODS

Trained pharmacists conducted interviews (30-45 min each) with clients of CMHTs to identify actual and potential drug-related problems. The pharmacists prepared medication review reports that detailed their findings and recommendations to optimize drug therapy. An expert panel comprising a psychiatrist, general medical practitioner, mental health pharmacist and medication review pharmacist evaluated reviews for 48 clients of 5 CMHTs. Panelists independently assessed review findings, review recommendations, likelihood of recommendation implementation and the overall expected clinical impact.

RESULTS

Two hundred and nine medication review findings and 208 medication review recommendations were evaluated. Panelists agreed with 76% of findings and considered that 81% of recommendations were appropriate. Collectively, 69% of recommendations were considered likely to be implemented. Thirty-seven (77%) reviews were deemed potentially to have a positive clinical impact. The agreement between panelists was statistically significant (P < 0.01) for the assessment of the findings, recommendations and likelihood of recommendation implementation.

CONCLUSIONS

Pharmacists' findings and recommendations to optimize drug therapy were considered appropriate and likely to result in improved clinical outcomes. Comprehensive medication reviews may be a valuable strategy to identify and resolve drug-related problems among clients of CMHTs.

Adverse Drug Reactions in Hospitalized Psychiatric Patients

BACKGROUND:

Reducing adverse drug reactions (ADRs) is a critical element in providing safe medication use to hospitalized patients. There is an abundance of literature describing ADRs and preventable ADRs (pADRs) in hospitalized patients; however, little has been published specific to psychiatric inpatients. Further knowledge of the most common pADRs in hospitalized psychiatric patients will allow targeted patient safety initiatives to be developed.

OBJECTIVE:

To determine the most frequent ADRs and pADRs in a psychiatric hospital, with emphasis on identifying factors for prevention.

METHODS:

Three years of ADRs at a psychiatric hospital were analyzed and evaluated according to type of medication, preventability, severity, and factors associated with preventability.

RESULTS:

From July 1, 2006, to June 30, 2009, 93 ADRs were reported; 19 (20.4%) were classified as preventable. Psychiatric medications accounted for 45 (48.4%) of the ADRs and nonpsychiatric medications were associated with 48 (51.6%). Cardiovascular agents (n = 17) and antiepileptics (n = 17) were responsible for most ADRs. Of the 19 pADRs, lithium was the drug reported most frequently, followed by phenytoin and anxiolytics. Nine (47%) of the pADRs were severe and required a medical transfer for management; 3 of the 9 were lithium toxicity. The most common preventability factor involved drug interactions. A pharmacy intervention involving staff education to reduce lithium pADRs is presented.

CONCLUSIONS:

Awareness of the most frequent drug classes associated with ADRs and pADRs in a psychiatric hospital allows opportunity for education, medication management system changes, and improved patient safety. Lithium, followed by phenytoin and anxiolytics, were the most common drugs associated with pADRs. A drug-drug interaction was the most frequent factor associated with pADRs.

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention

CONTEXT

Medications represent a major cause of harm and are costly for hospitalized patients, but more is known about these issues in large academic hospitals than in smaller hospitals.

OBJECTIVE

To assess the incidence of adverse drug events (ADEs) in six community hospitals.

DESIGN

Multicenter, retrospective cohort study.

SETTING

Six Massachusetts community hospitals with 100 to 300 beds.

PATIENTS

From 109,641 adult patients hospitalized from January 2005 through August 2006, a random sample of 1,200 patients was drawn, 200 per site.

MAIN OUTCOME MEASURES

ADEs and preventable ADEs.

METHODS

Presence of an ADE was evaluated using an adaptation of a trigger instrument developed by the Institute for Health Care Improvement. Independent reviewers classified events by preventability, severity, and potential for preventability by computerized physician order entry (CPOE).

RESULTS

A total of 180 ADEs occurred in 141 patients (rate, 15.0/100 admissions). Overall, 75% were preventable. ADEs were rated as serious in 49.4% and life threatening in 11.7%. Patients with ADEs were older (mean age, 74.6 years, p < 0.001), more often female (60.3%, p = 0.61), and more often Caucasian (96.5%, p < 0.001) than patients without ADEs. Of the preventable ADEs, 81.5% were judged potentially preventable by CPOE.

CONCLUSIONS

The incidence of ADEs in these community hospital admissions was high, and most ADEs were preventable, mostly through CPOE. These data suggest that CPOE may be beneficial in this setting.