What do we know about medication errors in inpatient psychiatry?

Abstract

Background: Adverse drug events (ADEs) have been implicated as a cause of substantial morbidity and mortality. Psychiatrists have successfully characterized one category of ADE--adverse drug reactions (ADRs), which have been studied from a medication-specific psychopharmacology frame of reference. The literature on ADEs, both preventable and nonpreventable, was reviewed within the broader patient safety framework.

Methods: English-language studies involving ADEs and medication errors in psychiatry for 1996 through 2003 were identified on MEDLINE and by using a hand search of bibliographies.

Results: Few reports on the incidence and characteristics of medication errors in psychiatric hospitals could be found. Psychiatrists may not be sufficiently aware of the harm caused by errors, methodological issues regarding error detection, the validity of reported medication error rates, and the challenge of creating a nonpunitive error-reporting culture. PREVENTION STRATEGIES: Application of a systems-oriented approach to ADE reduction and the promotion of a nonpunitive culture are essential. Clinical and pharmacy staff could monitor the literature for published reports of preventable adverse events and review those reports in multidisciplinary team meetings.

Conclusions: Psychiatry would benefit from learning about the terminology used in describing medication errors and ADEs. Relatively few data are available regarding the frequency and consequences of medication errors in psychiatry; more research is needed.