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Prevention of Medical Errors 
2 CEUs Prevention of Medical Errors

Manual of Articles Sections 1 - 6
Section 2
Medication Error in Mental Health: Implications for Primary Care

Question 2 | CEU Answer Booklet | Table of Contents | Medical Errors CEU Courses
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

The adverse consequences of error within healthcare are becoming increasingly apparent and improving patient safety is a key policy within health services across the world. [1–3] Medication is one of the main treatments for people with mental health problems and good quality primary care is increasingly vital in the health care of people with severe mental illness (SMI).[9–11] 
General practitioners (GPs) have been supported to develop a special interest in mental health and community pharmacists (CPs) may have a significant role, particularly if a single pharmacy dispenses all the service user’s medication. [7]Both GPs and CPs may lack knowledge, skills, confidence and formal training in mental health.[10,15] Moreover, inner-city GPs, who may see more patients with SMI, have less positive attitudes to the involvement of primary care in the treatment of SMI.[16]
Medication errors in primary care are a common problem across most healthcare systems. [17] Medication error in mental health, for example the failure to prescribe a treatment due to a communication error, could have severe consequences in this potentially vulnerable group. However, three recent reviews have highlighted that medication error within mental health is a vastly under-researched area, confirming a report by the American Psychiatric Association [18-21]. Most of the current research related to the inpatient environment, and there is an almost complete lack of data on the risks in the community—where most patients receive treatment.

Service Organizational Issues
Modern community based mental health services are fragmented, particularly following the establishment of specialist teams for home treatment, assertive outreach and early intervention. [22] This has created numerous interfaces which patients frequently cross between primary and secondary care and different parts of the services. Primary care clinicians may not be aware of medication supplied by secondary care colleagues, resulting in unintended drug interactions. [23]

Transitional care, when patients cross organizational boundaries, is associated with medication reconciliation errors. [24] Communication difficulties, complex medicine regimens, unclear roles and responsibilities, patient factors and the involvement of multiple professionals may increase the risk of medicine reconciliation errors.[25]

Primary care clinicians should be aware that transition across the primary–secondary care interface may be particularly associated with risk as various organizations (inpatient units, hospital pharmacy, general practice, and community pharmacy and community mental health teams) are potentially involved.

Physical Health
The physical health of people with SMI needs to be improved; compared to people with asthma, people with schizophrenia are less likely to have cholesterol, blood pressure and smoking status checks.[11] Any significant improvement is likely to need to involve a major contribution from primary care, in particular from GPs.[7,11] People with SMI already receive complex regimens including physical medicines, psychotropics and anti-convulsants, increasing the risk and severity of medication errors; further treatments for physical health will increase the potential for errors.[18,19,27–30]

Primary care may have a role in reducing the risk associated with physical medicines. In mental health organizations, prescribing errors with physical medicines may be twice as frequent as errors with psychotropics and administration errors are more likely to involve physical medicines [31-33].

Training Issues
A lack of training and familiarity with certain classes of medicines may increase the risk of errors. [19, 20, 35] However, whilst there is some evidence that the use of psychotropics within primary care is associated with an increased risk of error, robust data is currently lacking. [18, 20] The possible increased risk associated with physical medicines when used within mental health organizations may be due to a lack of training and an important role for primary care is supporting the management of such physical medicines. [19, 35]

Front-line mental health staff linking with primary care, including social workers, occupational therapists and support workers, may lack formal training in medicines management. Staff with limited knowledge could fail to act, or offer inappropriate advice; a sore throat due to clozapine induced neutropenia might not be viewed as significant and only symptomatic treatment recommended. The increasing use of non-medical prescribers, such as psychologists, may also increase the risk of medication errors, although currently evidence of this is lacking. [20]

Cognitive Impairment
 Patients intercept nearly a quarter of errors, but both medication and mental illness impair cognition and decision-making facilities an people with mental health problems may be less articulate and less likely to question a prescription, a change in medicine, whether monitoring is needed, or identify potential adverse events or a potential error. [18, 36, 37] Alternatively, if the patient does identify an error this view may be ignored due to capacity concerns. [38]

Impaired cognition and concerns about capacity occur most commonly during acute phase. Medication is more likely to be commenced and the care of the patient more likely to be transferred across organizational boundaries, particularly primary-secondary care interface, during the acute phase, increasing the potential for errors.

This potential lack of advocacy may mean that medication is not regularly reviewed; the recent UK all-party parliamentary report on dementia identified the lack of regular reviews of the medication regimens of people with dementia. [39] Primary care clinicians need to be aware that someone with mental health problems may not identify a medication error, placing additional responsibilities on clinicians and carers. [18]

Role of Carers
Carers carry out up to ten activities in relation to medicines and have a key role in identifying potential medication errors. [40,41] This role places significant strain on carers and the greater the number of activities the worse the social functioning and the mental health of the carer.[41] Carers may also believe that patients with impaired cognition are less likely to critically observe their actions and take less care, a so-called ‘Hawthorne effect’, increasing the risk of medication errors.[42]

Giving the wrong medicine to the wrong patient may be a particular risk with agency staff working in residential care facilities, who are unfamiliar with the patients. [30] Primary care healthcare professionals can improve safety by providing advice, ensuring that carers have sufficient knowledge about the medication and identifying if carers have any difficulty in understanding the instructions for administering medication. [43]

People with mental health problems may be at greater risk of a medication error however evidence is currently lacking. Primary care has an increasingly key role in improving medication safety. The complexity of mental healthcare services and training issues may increase the risk of errors, with the management of physical medicines an area of particular risk.

Patients may be cognitively impaired and fail to identify an error, placing greater safety burdens on clinicians. The role of carers in patient safety also requires consideration. The mistrust prevalent in mental healthcare services may impair information exchange, increasing the risk of errors.

--Maidment, I. D., & Parmentier, H. (2009). Medication error in mental health: implications for primary care. Mental Health In Family Medicine, 6(4), 203-207.

Personal Reflection Exercise #2
The preceding section contained information about medication errors in mental health. Write one case study example regarding how you might use the content of this section in your practice.

What do Carers say about patients with impaired cognition and the Hawthorne Effect? Record the letter of the correct answer the CEU Answer Booklet

CEU Answer Booklet for this course | Medical Errors CEU Courses
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Table of Contents

Excerpt from Bibliography referenced in this article
1. Department of Health. Building a Safer NHS for Patients – implementing an organisation with a memory. London: The Stationery Office, 2001.
2. Department of Health. An Organisation with a Memory. London: The Stationery Office, 2000.
3. Kohn L, Corrigan J and DonaldsonM(eds). To Err Is Human: building a safer health system. Washington DC: National Academy Press, 1999.
7. Department of Health. Guidelines for the Appointment of General Practitioners with Special Interests in the Delivery of Clinical Services: mental health. London: The Stationery Office, 2003. www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4006376
9 Department of Health. The National Service Framework for Mental Health – five years on. London: The Stationery Office, 2004.
10. Lester H. Current issues in providing primary medical care to people with serious mental illness. International Journal of Psychiatry in Medicine 2006;36:1–12.
11. Roberts L, Rolfe A, Wilson S et al. Physical health care of patients with schizophrenia in primary care: a comparative study. Family Practice 2007;24:34–40.
15. Phokeo V, Sproule B and Raman-Wilms L. Community pharmacists’ attitudes toward and professional interactions with users of psychiatric medication. Psychiatric Services 2004;55:1434–6.
16. Brown JSL, Weich S, Downes-Grainger ED et al. Attitudes of inner-city GPs to shared care for psychiatric patients in the community. British Journal of General Practice 1999;49:643–4.
17. Rosser W, Dovey S, Bordman R et al. Medical errors in primary care. Canadian Family Physician 2005; 51:386–7.
18. Maidment ID, Paton C and Lelliott P. A review of medication errors in mental health care. Quality and Safety in Health Care 2006;15:409–13.
19. Maidment ID, Haw C, Stubbs J et al. Medication errors in older people with mental health problems: a review. International Journal of Geriatric Psychiatry 2008;23:564–73.
20. Grasso BC, Bates DW and Shore MF. Medication Errors in Psychiatric Care: incidence and reduction strategies. 2007. www.medscape.com/viewprogram/7319_pnt (accessed 2 April 2009).
21. American Psychiatric Association. Patient Safety and Psychiatry. 2003. www.psych.org/psych_pract/pract_mgmt/apa_patientsafety_toc21003.pdf
22. Department of Health. The NHS Plan: a plan for investment a plan for reform. London: Department of Health, 2000. www.dh.gov.uk/assetRoot/04/05/57/83/04055783.pdf
23. Morcos S, Francis SA and Duggan C. Where are the weakest links? Psychiatric Bulletin 2002;26:371–4.
24. Department of Health. Building a Safer NHS for Patients: improving medication safety. London: The Stationery Office, 2004.
25. National Institute for Clinical Excellence. Technical Patient Safety Solutions for Medicines Reconciliation on Admission of Adults to Hospital. 2007. Alert reference:NICE/NPSA/2007/PSG001.
27. Blass DM, Black BS, Phillips H et al. Medication use in nursing home residents with advanced dementia. International Journal of Geriatric Psychiatry 2008;23:490–6.
28. Tomasi R, de Girolamo G, Santone G et al. The prescription of psychotropic drugs in psychiatric residential facilities: a national survey in Italy. Acta Psychiatrica Scandinavica 2006;113:212–13.
29 Kreyenbuhl JA, Valenstein M, McCarthy JF et al. Long-term antipsychotic polypharmacy in the VA health system: patient characteristics and treatment patterns. Psychiatric Services 2007;58:489–95.
30. Maidment ID and Thorn A. A medication error reporting scheme: an analysis of the first 12 months. Psychiatric Bulletin 2005;25:298–301.
31. Haw CM and Stubbs J. Prescribing errors at a psychiatric
hospital. Pharmacy in Practice 2003;13:64–6.
32. Rothschild JM, Mann K, Keohane CA et al. Medication safety in a psychiatric hospital. General Hospital Psychiatry 2007;29:156–62.
33. Haw CM, Stubbs J and Dickens G.Medication administration errors in older psychiatric inpatients. International Journal of Quality in Health Care 2007; 19:210–16.
35. National Patient Safety Agency. Safety in Doses: learning from national reporting 2007. NPSA, 2009. Available at: www.nrls.npsa.nhs.uk/resources/?entryid45=61625
37. Barber ND,Alldred DP, RaynorDKet al. Care homes’ use of medicines study: prevalence and potential harm of medication errors in care homes for older people. Quality and Safety in Health Care 2009; 18:341–6.
38. Seale C, Chaplin R, Lelliott P et al. Sharing decisions in consultations involving anti-psychotic medication: a qualitative study of psychiatrists’ experiences. Social Science and Medicine 2006;62:2861–73.
39. All-Party ParliamentaryGrouponDementia. Always a Last Resort: inquiry into the prescription of antipsychotic drugs to people with dementia living in care homes. 2008. www.alzheimers.org.uk/downloads/ALZ_Society_APPG.pdf (accessed 27 April 2009).
40. Smith F, Francis SA, Gray N et al. A multi-centre survey among informal carers who manage medication for older care recipients: problems experienced and development of services. Health and Social Care in the Community 2003;11:138–45.
41. Francis SA, Smith F, Gray N et al. The roles of informal carers in the management of medication for older-care recipients. International Journal of Pharmacy Practice 2002;3:1–10.
42. Nirodi P and Mitchell AJ. The quality of psychotropic drug prescribing in patients in psychiatric units for the elderly. Aging and Mental Health 2002; 6:191–6.
43. Goldstein R and Rivers P. The medication role of informal carers. Health and Social Care in the Community 1996;4:150–8.

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