The medication process in a psychiatric hospital: are errors a potential threat to patient safety?

Ann Lykkegaard Soerensen,^1,2 Marianne Lisby,³ Lars Peter Nielsen,⁴ Birgitte Klindt Poulsen,⁴ Jan Mainz<sup>5,6

1</sup>Faculty of Social Sciences and of Health Sciences, Aalborg University, Aalborg, Denmark; ²Department of Nursing, University College of Northern Denmark, Aalborg, Denmark; ³Research Centre of Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; ⁴Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark; ⁵Aalborg Psychiatric University hospital, Aalborg, Denmark; ⁶Department for Health Services Research, University of Southern Denmark, Denmark

Purpose: To investigate the frequency, type, and potential severity of errors in several stages of the medication process in an inpatient psychiatric setting.
Methods: A cross-sectional study using three methods for detecting errors: (1) direct observation; (2) unannounced control visits in the wards collecting dispensed drugs; and (3) chart reviews. All errors, except errors in discharge summaries, were assessed for potential consequences by two clinical pharmacologists.
Setting: Three psychiatric wards with adult patients at Aalborg University Hospital, Denmark, from January 2010–April 2010.
The observational unit: The individual handling of medication (prescribing, dispensing, and administering).
Results: In total, 189 errors were detected in 1,082 opportunities for error (17%) of which 84/998 (8%) were assessed as potentially harmful. The frequency of errors was: prescribing, 10/189 (5%); dispensing, 18/189 (10%); administration, 142/189 (75%); and discharge summaries, 19/189 (10%). The most common errors were omission of pro re nata dosing regime in computerized physician order entry, omission of dose, lack of identity control, and omission of drug.
Conclusion: Errors throughout the medication process are common in psychiatric wards to an extent which resembles error rates in somatic care. Despite a substantial proportion of errors with potential to harm patients, very few errors were considered potentially fatal. Medical staff needs greater awareness of medication safety and guidelines related to the medication process. Many errors in this study might potentially be prevented by nursing staff when handling medication and observing patients for effect and side effects of medication. The nurses' role in psychiatric medication safety should be further explored as nurses appear to be in the unique position to intercept errors before they reach the patient.

Keywords: medication safety, mental health disorders, medication errors, psychiatry