The Joint Commission Video on Speaking Up to Avoid Medical Errors 2011
Delivering the right care to the right patient at the right time in the right way is a historical challenge that has been appreciably exacerbated by modern medical complexities. It takes everyone from the patient or client, through the healthcare professionals both from the bottom to the top being willing to watch for areas at risk and speaking up about how to avoid medical errors.
The serious problem of medical errors is not new. Even with the recent emphasis, there continues to be a significant amount of injury to patients caused by the delivery of medical care.
This course was developed to provide a foundation for a better understanding of what
medical errors are, where they most frequently occur, how to address
them using processes such as the root cause analysis and how to avoid them through error reduction and prevention techniques. Improvement approaches, analysis tools, reporting processes, and risk management issues for inpatient and residential programs will be discussed.
Patient and family participation will be highlighted as a key component of safety.
Finally, outpatient practitioner issues relating to medical errors will be explored. These
topics will explore ways to encourage safety and improve outcomes for patients.
As this course uses the term adverse event it is used to describe an injury caused by medical mismanagement rather than an underlying disease/condition of a patient or client.
The term error planning is used to describe the use of a wrong plan to achieve the desired aim and error execution is used to describe the failure of a planned action to be completed as intended. Not all, but a sizable number of adverse events are a result of medical errors. Careful analysis and then process implementation can help prevent these medical errors from happening.
As many professionals in the same industry work in very different setting, as you continue through this course, think about implications for your work environment and practice.
The Leading Causes of Errors
Health care professionals continue to be placed in situations wherein errors are bound to occur. For example, inexperience and poor training can lead to inaccurate diagnosing and treatment and a higher rate of human error. Inadequate staffing levels have been linked to an increase of adverse events. Overwork and fatigue have been shown to cause a significant decrease in alertness and concentration leading to errors. Reliance on memory, which is fallible, can also lead to compromised patient safety.
Most people believe that medical errors are the result of the failures of individual providers. When asked in a survey sixty-nine percent of respondents thought the problem could be solved through better training of health professionals. In actuality, the IOM emphasized that most of the medical errors are systems related and not attributable to individual negligence or misconduct. The best approach to reducing medical errors is to focus on improving the systems for caring for and treating clients and not to blame individuals.
Healthcare professionals are humans and, like everyone else, they do make mistakes.
Although research has shown that system improvements are key to reducing the error
rates and improving the quality of healthcare it is also important to explore why
professionals are prone to mistakes. Research in the healthcare industry, as well as in
other industries, such as long distance trucking, aviation and nuclear power have offered insight into how people make mistakes and how we can use this learning to improve systems and make patient care safer. Research supports that people make mistakes due to fatigue. Mistakes are more likely as people get tired. Inattention and distraction, when multiple events are occurring at the same time, can divert attention from the task at hand. Also, seeing what we expect to see because we are used to seeing it that way, even if it is incorrect often leads to mistakes that we don’t even recognize. Encountering a new situation in which we have not been trained and do not know how to handle can lead to using trial and error solutions often resulting in error. Communication problems and information transfer problems, this would include lack of communication, misinterpretation and using words that have more than one meaning, can contribute to errors. Legibility, such as handwritten notes and orders, which can lead to guessing can lead to errors. In the hospital setting, the labeling of medications or mislabeling equipment instructions may be misleading. Frequently, mistakes are made when the equipment, supplies or the environment are not conducive to the safest practices.
In the mental health field, professionals are bound to encounter many different types of clients. The patients are considerably varied with different conditions, preferences and openness. In many situations the client is the primary source of information from which a history is created, a diagnosis is made and a treatment plan is developed.
It is also relevant to expect any process involving multiple patients to be prone to have more failure.
Complex processes are more prone to failure because each additional step is a process that is one more chance for a mistake to happen.
A process that involves human intervention, and counseling largely does, is more prone to error. For example, automated functions often proceed smoothly, and without interruption, computer alerts, and calculators are examples of technology that maintain process stability without needing people to do the work. Time constraints often go hand in hand with errors. When time is limited for a process, or it must occur rapidly, then additional pressure and stress are applied to the people taking that action. Nerves often get frazzled during rush hour traffic, so do they also get frazzled while trying to complete a task, getting a report to the court system, moving a patient to an appropriate unit, or trying to get medications to the patient promptly. The last to note is a hierarchical culture. When there is a fear of reprisal, it makes it difficult to raise issues for fear of being
embarrassed or being wrong.
The reduction of errors involves understanding how people perform, how people think, how people communicate with one another, and how people interact with technology
in complex organizational systems. So a systems approach to understanding both safety and error involves multiple domains within scientific psychology.
Research shows that the majority of medical errors can be prevented. A landmark study
on medical errors indicated 70 percent of adverse events found in a review of 1,133
medical records were preventable; 6 percent were potentially avoidable, and 24 percent were not avoidable. It is a common misconception that client safety can be improved by merely reminding health care personnel to be more careful. To correct the root of medical errors, instead of focusing on blaming an individual for an incident, the focus should be on reviewing the processes and factors that surrounded the event. A change in focus can occur only by health care professionals carefully evaluating their processes and previous errors and then systematically making the positive changes. Improving patient safety is about changing the culture of healthcare.
Hindsight is 20/20. Hindsight bias is the phenomenon where it seems obvious how an error happened but after the fact. However, before the error occurred, it was not apparent that the process or system was error-prone. Hindsight bias is detrimental to accident analysis and understanding because it narrows the focus of the cause of any failure without considering the whole picture, including all of the environmental and emotional issues,
which may surround the event. This approach will limit a complete and thorough investigation and focus on individual action as the cause of the problem. We often jump to conclusions without having all of the necessary information.
There are several methodological reasons why research in patient safety is particularly challenging. Many practices, particularly in counseling, cannot be the subject of double-blind studies because their use is evident to the participants. Also, capturing all relevant outcomes, including “near misses and harmful events, are often very difficult. Many effective treatment plans are multidimensional and sorting out precisely which part of the intervention works is often quite challenging.
As researchers have concluded, most medical errors cannot be prevented by perfecting the technical work of individuals, instead of implementing prevention techniques as a means of crosschecking and monitoring progress is necessary to improve outcomes.
FMEA assumes that no matter how knowledgeable or careful people are, errors will occur in some situations and may even be likely to occur. FMEA steps include first defining high
risk processes, identifying what could go wrong, the significance of the error and what
needs to be done to prevent failures.
How Miscommunication Can Translate Into Error
Listening skills are well noted as one of the essential counseling attributes, the way we talk, and the words we use to describe an event help to shape treatment.
Whether communicating in a group with clients or talking with counselors in supervision, redefining our culture for safety must include placing words in concepts, and understanding the whys of why things happen. Think about the terms of accident versus failure versus
error. “Accident” describes a breakdown in a system. Frequently, they are complex, and they need analysis. “Error” suggests one cause, usually notes that of a human error. There is infrequently a single cause of an accident. An example, a client comes in to take the SASSI (Substance Abuse Subtle Screening Inventory), which is a self-administered test for alcohol and other drug abuse, they fill out the answer form incorrectly, but this is not evident from just looking at the form. The clinician scores the test and develops a treatment plan with the score as a factor. If the client is not in the best therapeutic environment, is there one cause for this?
To prevent future errors, we must learn from our mistakes. Let’s face it; we all make mistakes. Mistakes happen in hospitals, they occur in outpatient settings, and they happen in nursing homes. We, as professionals, need to feel safe enough and respect our profession sufficient to acknowledge that they happen. The challenge is to avoid them,
and when mistakes do occur, to prevent them from causing harm to our clients. While understanding the legal ramifications of such, we must admit that we made a mistake so that others and we can learn from it.
Accidents are not isolated events; they are the result of a weakness in a system. Blame is used to find an excuse for failure not to predict and prevent future incidents. A blameless environment promotes comfort to report failures for study. What happened versus whose fault is it; “what” uncovers facts, “who” always place blame.
I never understood why working in the mental health field, and we did not support each other better. We know how powerful words can be. Choose them carefully with the best end result in mind.
Clients at Risk
Again, it is easy to think of the areas in the medical/surgical arena that medical errors could occur. In actuality, many disciplines are vulnerable to mistakes. They can occur in
nursing, dietary, physical therapy, occupational therapy, radiology, nuclear medicine,
laboratories, surgery, and many others, including social services. Examples include a
clinician misreading the results of a test or drug screen or the dates in a court-mandated
treatment file suggesting the client has completed 36 weeks of treatment when this isn’t
Many errors occur when clinicians and their patients have problems communicating.
This can certainly happen in the mental health field. A recent study supported by the
Agency for Healthcare Research and Quality (AHRQ) found that doctors (the same can be said for many clinicians) often do not do enough to help their patients make informed decisions. A critical factor in effective psychiatric treatment is patient involvement.
Uninvolved and uninformed patients are less likely to accept the choice of treatment and less likely to do what they need to do to make the treatment most productive. The goal of safety programs is to create a non-punitive and blameless culture. This means that when an error occurs instead of placing blame on the person involved, exploration of the situation and the surrounding events should be analyzed. The reporting is necessary to see what is wrong with the process or the procedure. A simple process mandating that a
colleague must proof all evaluations before being sent out, or a supervisor must review test results before a treatment plan is developed with the client can make a big difference with accuracy. Administrators and leaders can make changes and improvements easier for everyone to be a part of. The language of safety should be a positive one. Through these changes, the staff is empowered. All staff is aligning on the same agenda. Change from individual blame to system identification to reduce the number of medical errors and improve client outcomes.
Specific Areas of Concern for Errors in the
Mental Health Industry
Understanding that the nature of counseling is largely reliant on client information is a key
to recognizing where psychologists, counselors, and social workers will be most vulnerable.
Great care should be taken when eliciting the client’s history. Several methods should be utilized to reduce missing important information. Paperwork, the patient, fills out that asks questions such as previous treatment and diagnosis can begin the process. Face to face
evaluation and assessment time can cross-reference an understanding of the questions and further develop the picture of the person in front of you. Training in practical ways of building rapport and asking difficult questions can be helpful. The use of other informants, with a release of information, can be useful. For example, a spouse, sponsor, or previous counselor can give additional information. Another area of frequent confusion in the inpatient setting is advanced directives and patient rights. Misinformation on these issues can lead to great frustration on the part of the patient and derail an otherwise productive therapeutic relationship. This is true for involuntary commitment, as well. A thorough understanding of your state requirements and a polished approach to explaining the rights and the process to the patient and family can make a dramatic difference. One of the most significant issues relating to error is confidentiality. It is crucial to the therapeutic relationship, as well as for legal reasons, to be very clear on your professional, ethical, and states legal requirements for confidentiality. Not only in expressing in advance to a client what is and what is not confidential but also in the appropriateness and correctness of the information being reported from a treatment perspective. Is it therapeutic for a client to have access to the notes you are making in their chart? Are the notes saying what you mean for them to say if, for example, a judge requests the chart? Do you have a correct history, the same history the probation officer or managed care case manager knows of, if not, will the rest of your assessment look flawed?
Suicides by Mental Health Patients
Should suicide be considered the result of medical errors? In some cases, it is.
For several years, it has been recognized that a significant means of suicide in acute psychiatric units have been hanging from curtain or shower rails. The report
of the National Confidential Inquiry into Suicide and Homicide by People with Mental
Illness concluded that hanging from non-collapsible structures such as bed, shower, and curtain rails are still the most common method among mental health in-patients.
This is despite the fact that collapsible rails are now readily available. These are
What Changes Should Be Considered To Keep Clients Safer?
Health care professionals continued to be placed in situations wherein errors are bound to occur. For example, inexperience and inadequate training can lead to inaccurate diagnosing and treatment and a higher rate of human error. Insufficient staffing levels have been linked to an increase in adverse events. Overwork and fatigue have been shown to cause a significant decrease in alertness and concentration leading to. Reliance on memory, which is fallible, can also lead to compromised patient safety.
The core recommendations to reduce errors include:
1. Simplification reduces the number of steps and handoffs.
2. Standardization, limit the variety of test instruments used, equipment, supplies, policies, and processes.
3. Reduce reliance on your memory. Make client notes immediately after sessions.
4. Use a checklist as reminders to ensure complete, accurate actions. An example is to make a checklist that goes in the front of a client file to make sure all of the necessary paperwork, such as the signed confidentiality statement, releases, and notes are all in each file.
5. Eliminate look-a-likes and sound-a-likes, particularly for psychiatric nurses and pharmacists.
6. Eliminate similar labels that can reduce the chance of choosing the wrong item.
7. Training staff on patient safety error analysis techniques and tools and process improvement.
8. Increase communication feedback. Use feedback to modify or decrease error-prone
9. Create a learning environment.
10. Teamwork. Use teams to promote both multidisciplinary perspectives in identification and solution.
11. Make appropriate environmental adjustments.
12. Identify factors in the environment that may contribute to errors and modify them or correct them.
13. Adjust work schedules as needed. Identify factors in schedules that might contribute to errors, modify, and correct them.
The staff with direct contact with the clients is the last line of defense between effective care and a potential error. If we wish to accomplish our goal of protecting the patient from medical errors, then we must be proactive in examining risk-prone areas in which we work.
Many times we get lucky and have what can be termed a near miss. A near miss error can be described as an error that got caught before it reached the patient. Identifying and analyzing errors that are considered “near miss” errors can allow us to prevent future harm by determining where the weak parts are in the care delivery system and then strengthening those areas.
An essential aspect of adequate care is to look at the age-appropriateness of the treatment and plans. The following factors must be considered 1) the clients’ emotional ability to cooperate with care. 2) clients who need additional watching because they are a risk to themselves or others or due to their inability to care for themselves. 3) for the psychiatric nurse, reducing medication dosages per the doctor for children, elderly, and those with conditions of the impaired renal, liver, and immune function. 4) ability of different age groups to follow directions related to safety and asking for help. 5) assessing cultural differences may also play an important part in safe and effective care. Always evaluate for any language
barriers that inhibit understanding about care and or safety. Explore cultural differences in expressing psychiatric, emotional, and healthcare concerns.
Most counselors are not licensed or trained to dispense medications, however in the case of a psychiatric nurse who is also educated as a counselor, and medication administration is an extremely complicated task that many medical errors can be attributed to. The IOM study estimates that as many as 7,000 patients die each year as a result of medication errors with an estimated additional hospital cost of 4,700 dollars for each preventable medication error.
Medication errors can be broadly categorized into four major categories. The first, ordering and prescribing accounts for 39%. The second, dispensing is approximately 12%. The third, administration is 38%, and transcribing is 11%. So, almost 80% can be described as order, prescribing, or administration. As this course is predominately developed for counselors, social workers, therapists, and psychologists, we will not go further into these types of medication errors. For a more in-depth study of medication errors, please refer to
the Medical Errors course in the nurse category.
Another area of concern is procedural mishaps. These may include a variety of errors that occur or have the potential to occur while the client is navigating through the health care system. These mishaps may be as simple as discharging a client from a residential program
without the proper discharge recommendations.
Patients are at risk for serious injury, and organizations must deal with the financial liability that results from such accidents. Those who are at most risks for falls are the elderly or those under the influence of alcohol,
other drugs, or heavy medications. Falls may be caused by environmental factors, such as clutter in the room, wet floors, rugs; psychological factors; muscle problems or broken bones; noncompliance; incomplete histories, or lack of identification of falls risk.
Each year, one in every three adults age 65 and older falls. Preventing or reducing the number of falls is a challenge in most healthcare settings, but the challenge is even greater in the mental health facilities and units. In the psychiatric or behavioral health setting, fall rates range from 4.5 to 25 falls per 1,000 patient days.
As noted above, many factors contribute to patient falls. These factors can be intrinsic, extrinsic, situational, or a combination.
- Intrinsic factors associated with an increase in falls in a behavioral health unit include impaired cognition resulting from a chronic condition such as Alzheimer disease or an acute condition such as delirium. In addition, psychotropic medications and their adverse reactions may increase the likelihood of patient falls. Other intrinsic factors that may lead to falls include mobility, gait, vision, and balance disorders.
- Extrinsic factors (environmental factors) that may contribute to patient falls in a behavioral health unit include a lack of support equipment, such as side rails when patients are getting into and out of bed, or a lack of durable medical equipment (DME), such as walkers, canes, and lifting devices. To add to these problems, mental health units have environmental restrictions to protect patients from harm. For example, wired chair and bed alarms, side rails, and call systems with cords can endanger patients and staff. These issues can account for the lack of support equipment or DME.
- Situational factors (factors related to activities) occur when patients are attempting to perform more than one task at a time, such as getting out of a wheelchair while conversing.
Further measures include tracking and trending fall data, including the day of the week, shift, time, location, assistive devices present or not present, diagnoses, and medications. Sharing the monthly and quarterly analyses with front line staff, managers, and leaders of the organization helps programs apply human factors engineering concepts and a systems approach to fall prevention. To help prevent repeat falls, post-fall research assists in identifying what, when, where, who, and how. Barriers related to communication, staff training, patient education, environment, and equipment are included in each fall analysis.
To take a look at the organization as a whole, an annual retrospective review of all falls occurring during the year by an interdisciplinary group allows for input from subject matter experts to make system improvements. Team members may include nurses, physicians, pharmacists, and staff from rehabilitation services, prosthetics, and supply distribution.
Incorporating evidence-based practices into clinical practices improves patient safety. Some evidence-based practices include using an appropriate fall risk assessment tool, proper footwear, suitable signage, staff education, sitters, and safety rounding. All interventions used provide information that can be useful in identifying trends.
A fall risk assessment tool, including the Morse Fall Scale, should incorporate a list of drugs that place mental health patients at the highest risk for a fall. Facilities can modify their tool according to their patient population. The medications most often associated with falls include:
- selective serotonin-reuptake inhibitors
- tricycliantipsychotic agents
- antiepileptic drugs
- class IA antiarrhythmic agents
As noted by Life Point Hospice, falls prevention basics include:
1) assessment of a patients risk of falling
2) assessment of environmental dangers
3) patient and family teaching
4) continuance monitoring
5)implementation of a patient’s specific plan for safety providing a safe environment including removing any hazards, providing adequate lighting, lock beds and wheelchairs, placing objects within reach of patients, and always ensuring that there is a method for patients to call for assistance.
Anticoagulants increase the risk of bleeding, injury, and death in patients who fall. Medication reconciliation that includes the type of anticoagulant, the duration of the anticoagulant therapy, and dietary restrictions should be considered in fall risk assessment. Report adverse drug reactions, such as abnormal bleeding, to the prescriber so that dosage can be adjusted.
Hourly rounding, when executed and used properly, is an evidence-based practice that can reduce falls on any unit. In the case of the mental health and substance abuse patients, hourly rounding is b
ased on patient needs identified after completion of the fall risk assessment. The American Psychiatric Nurses Association surveyed nurses about facilities’ standard minimum rounding practices and found that nurses at about 60% of psychiatric facilities are rounding every 15 minutes. Many falls can be prevented by combining hourly rounding with other interventions.
Technological innovations include virtual side rails that serve as monitors to alert staff to patients who are attempting to get out of bed without assistance. While these aren’t physical rails that might harm patients, they allow for immediate staff notification and rapid response to patients who may fall and need assistance.
Assess a patient’s fall risk upon admission, change in status, transfer to another unit, and discharge from the facility. Implement an electronic fall risk assessment that will trigger a consult for rehabilitation services. Use sitters and assign high-risk patients to rooms closer to the nurses’ station to increase patients’ visibility.
- Engage patients and their families in all components of a fall prevention program. Teach patients about their medications and potential adverse reactions.
- Before assisting with mobility, evaluate the patient’s coordination and balance, then make sure resources needed are available. Ensure that all movable equipment such as beds and wheelchairs are locked before moving the patient.
- In the mental health environment, don’t leave equipment unattended that could be mobilized by the patient. For example, wheelchairs and bedside commodes can be used as weapons to harm patients and staff.
- Before leaving a patient, be certain that lighting is adequate to prevent tripping.
- Initiate a bowel and bladder program to decrease the patient’s attempts to get up without assistance due to urgency.
- Apply appropriate nonskid footwear to help provide traction.
- Assess and optimally manage pain.
- Assess for orthostatic hypotension and teach the patient to change positions slowly.
Partnering with providers
Inform healthcare providers of changes in a patient’s gait, posture, or spasticity. Performing medication reconciliation will help the provider and pharmacist prevent duplication of medications and drug interactions that can adversely affect patients. Be aware that changes in the medication regimen by providers may lead to adverse reactions associated with polypharmacy and could contribute to a fall.
When mental health problems are coupled with decreased or limited mobility, patients are at high risk for falls. Initiating fall prevention measures is a collaborative effort.e environment of psychiatric patients must be regulated, physical rehabilitation services should be initiated early to assess, evaluate, and manage gait issues. Having an electronic trigger to notify the healthcare provider when physical rehabilitation is needed closes the gap in communication. You initiate the trigger by completing a fall risk assessment.
Patients Rights and Protections
Communication from the initial consent to treat the disclosure of an unanticipated outcome is paramount to effective, therapeutic, safe care. Communication is the key. All providers involved in the course of treatment should maintain open communication with the client and as appropriate the client’s family.
Proper incident reporting identifies problem areas, provides the necessary information to establish safe practices, systems to ensure proper treatment and accurate files and to improve staff development. There are several barriers to reporting mishaps, including lack of time, fear of punishment, losing referrals, being taken off of a managed care panel, fear of being wrong, unclear reporting structures, or forgetfulness. An established line of communication through your supervisor will assist in performance improvement processes.
The goal of any reporting system is to analyze the information gathered and to identify ways to prevent future errors from occurring.
Clients develop through a variety of ways, seeing, hearing, touching, and doing.
Remember to incorporate as many techniques as possible to ensure the maximum amount learned and retained. Frequently, providing brochures and other written materials can help to emphasize how the client and their family can better and help their treatment along. Encourage patients to ask questions about their treatment plans and goals to be sure they know.
Research about medication errors in the mental health field is limited. In particular, very little is known about the incidence of error in non‐hospital settings or about the harm caused by it. Evidence is available from other sources that a substantial number of adverse drug events are caused by psychotropic drugs. Some of these are preventable and might probably, therefore, be due to medication error.
The following excerpt is from a study completed by Ian D. Maidment, Paul Lelliott and Carol Paton and was published in the Quality and Safety in Healthcare in the UK. The excerpt is a portion of the article and posted in its entirety.
This review shows that medication error in mental healthcare is a neglected aspect of research. In particular, there have been no systematic studies of patients living in the community. Therefore, the potential for mental health services to prevent harm and deaths from medication error is unknown. Consistent with this, the issue is not high on the mental health policy agenda in the UK, where the overwhelming priority for risk management has been the prevention of suicide and homicide by people with mental illness. Prevention of suicide is a key government policy initiative and concern about homicides by people with mental illness has been one of the main drivers of recent mental health service reform. Despite this emphasis, the potential for specialist mental health services to prevent suicide or homicide is quite modest. Each year, in England and Wales, there are about 1200 suicides and 50 homicides by people who have had recent contact with mental health services. Perhaps one-fifth of these events could have been prevented by some action of the concerned mental health service. This would equate to about 4.6 potentially avoidable deaths per million population each year.
The broader research literature on adverse events involving psychotropic drugs was not included in the systematic review, because the studies do not identify which adverse drug events are preventable and hence would be classified as a medication error. However, they do show that psychotropic drugs cause substantial harm and suggest that mental health services might have greater potential to prevent deaths from adverse drug events than to prevent deaths from suicide and homicide. For example, the largest English study of its type estimated that adverse drug events caused 6.5% of all admissions and might account for about 6000 deaths each year. Antidepressants were implicated in 7% of these admissions. The proportion of admissions due to psychotropics would certainly be higher if admissions because of intentional overdoses are included.
The remainder of this discussion considers what might be the priorities for future research on medication error in mental healthcare services and the potential of research to identify and quantify its causes. It draws on evidence about adverse drug events and inadequate prescribing practice. We suggest that some types of medication error might be more common in mental health services, due to particular characteristics of the organization and delivery of mental health services, and of the client group.
Communication difficulties in mental health services
One consequence of the move to community care is that modern mental health services are fragmented. In the UK, this has been accentuated by the recent NHS plan which requires the establishment of specialist teams for home treatment, assertive outreach, and early intervention. This has created numerous interfaces between primary and secondary care, between hospital and community services and between different components of the community mental health service. Patients with severe and relapsing mental illness often cross these interfaces.
Problems of communication cause more than two-thirds of treatment errors in medical practice and errors are likely when information is transferred across organizational boundaries. In one study, potentially harmful medication errors occurred in 24% of psychiatric admissions and in 18% of discharges. In another 41 of 58 medicines that mental health patients were taking were not consistently recorded in both the primary and secondary care records. In particular, secondary care records tend to omit non‐psychotropic drugs. Junior doctors may take incomplete or inaccurate histories of medication on admission, partly because of reliance on a single source of information such as the general practitioner’s letter. Primary care records may omit psychotropics, including medicines supplied by mental health services, such as clozapine, depot injections, and cholinesterase inhibitors.
Role of the multi-professional team in medicine management
Two particular situations might warrant more systematic research on medication errors. The first is the frequent use of medication prescribed to be given “as required” at the discretion of nursing staff in mental health inpatient units. One study found that the quality of prescribing as required medication was considerably poorer than that of regular medication. The potential risk is illustrated by a census of 3132 inpatients prescribed antipsychotics, which found that as required medication sometimes gave nurses the option of giving doses above the recommended range. The second situation is the role that members of community mental health teams have in monitoring medication in people with severe and enduring mental illness. These team members come from a wide range of disciplines, and many have received no training in the uses and potential side effects of psychotropic drugs. This increases the risk of unintentional harm in two ways: through inappropriate advice and through failure to act. An example of the first type of error is a team member encouraging a patient who has been non‐compliant with clozapine for a week to restart at the full dose, rather than reiterate the dosage, with the potential risk of adverse events such as marked postural hypotension. An example of the second type of error is a failure to recognize and act on potentially important physical health problems, such as a sore throat and fever in a patient receiving clozapine, or increasing thirst and tiredness in a patient taking an antipsychotic drug.
Decision‐making errors in mental healthcare
Psychiatrists often fail to screen adequately for the adverse effects of psychotropic drugs. This includes screening for the metabolic syndrome for patients prescribed atypical antipsychotics and for adverse effects and toxicity in patients prescribed lithium. This may result in modifiable factors for premature death being untreated. Research on the cause of these failures to monitor for adverse drug reactions might inform the design of training interventions to deal with deficits in knowledge and systems that reduce the frequency of slips and lapses.
The problem of medication error related to inadequate prevention and management of adverse effects might be compounded by the frequency with which psychiatrists prescribe outside the product license. Although such “off‐label” prescribing may sometimes be appropriate, it may increase the risk of harm through inadequate monitoring. For example, safety alerts concerning drugs not licensed for psychiatric conditions, such as anticonvulsants prescribed as mood stabilizers, may not be directed to psychiatrists. Another example is the off‐label prescribing of high‐dose antipsychotics. This is associated with a higher incidence of adverse reactions to drugs and requires close monitoring. There is evidence that this often does not happen.
Two other situations, particularly in mental healthcare, are observed in which poor decision making may be a factor in preventable harm owing to adverse reactions to drugs. The first is the use of medication to manage acutely disturbed behavior. There is good evidence that monitoring of the patient is often inadequate after giving the medication despite the possible association between rapid tranquilization and death from a cardiovascular event. The second situation is the prescription of toxic psychotropic drugs to people at risk of suicide. About 11% of deaths owing to drug overdoses involve antidepressants; this equates to 50 deaths each year. The prescription of less toxic antidepressants might prevent some of these deaths.
Factors related to patients
Patients with mental health problems may be less articulate and less likely to question a prescription, a change in the medication regimen, potential side effects or whether monitoring is required. This, together with the fact that some patients might have reduced capacity, places additional responsibilities on mental healthcare staff. This applies particularly to mental health wards for older people where many patients have dementia.
Poorly developed prescribing systems and pharmacy services
Many UK mental health services have poorly developed systems to aid communication and support safe medication management. There is also a lack of standardization so that clinicians who move between services are confronted with unfamiliar systems for prescribing, obtaining, handling and administering medication. Many inpatient units and community mental health teams have limited IT infrastructure, unintegrated, paper‐based record systems, little decision support for prescribing and poor access to laboratories for monitoring.
Pharmacists are effective at detecting and preventing some serious prescribing errors. In mental health services, the problems caused by poor prescribing systems are compounded by the inadequate staffing and organization of pharmacy services. Some mental health services have limited pharmacy infrastructure and so have limited awareness of, or strategic capacity to improve, medication management. Poor staffing levels, inadequate training, lack of appropriate clinical expertise and lone working without adequate clinical supervision are features of the service. In many mental health trusts, pharmacy services are contracted in from acute care providers through service‐level agreements. This can compound problems as the staff are employed by another organization whose systems of working may not prioritize mental health.
Organizations successful in improving patient safety have designed systems to protect against human shortcomings. They have made significant strides in improving safety through the use of system approaches such as automation, simplification, and standardization of functions and equipment; practice guidelines or protocols; and teamwork that includes checks and balances.
Furthermore, error reduction is a philosophy embraced throughout the organization from top to bottom.
To improve safety in the modern health care system, similar philosophies must be embraced, and related changes must be made. It is the knowledge that both opportunity
and potential for improvement exists in the health care system that leads to a call for
rigorous research focused on preventable system errors and improve patient safety.
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