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. 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.
Medication errors in primary care are a common problem across most healthcare systems.  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.  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. 
Transitional care, when patients cross organizational boundaries, is associated with medication reconciliation errors.  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.
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.
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. 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].
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. 
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. 
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.  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. 
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. 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.
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.  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. 
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.
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
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