You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.
 

 

Medication Errors in Psychiatric Care: Incidence and Reduction Strategies

processing....

Conclusions

Psychiatric medication errors have not been sufficiently studied despite the presence of several risk factors for their existence and for harmful clinical consequences. We found 2 medication error incident reports:

  1. The study by Grasso and colleagues in 2003[7]

  2. The study by Senst and colleagues in 2001[22]

We found no studies in psychiatric settings that used an independent audit to identify medication errors and then examine a potential causal link between errors and clinical harm.

Psychiatry professional organizations have only recently identified medication errors as a patient safety and quality concern. The American Psychiatric Association (APA) first convened its Task Force on Patient Safety in 2002.[53] Adverse medication events were identified as number 1 out of 4 areas of priority. The Task Force recommendations were approved by the Board of Trustees on November 24, 2002, and by the Assembly Executive Committee on January 24, 2003, leading to the inception of the APA Committee on Patient Safety.

Recommendations

Independent audits. Medication errors in inpatient psychiatry deserve more study. If the studies of inpatient psychiatric settings and general care settings are considered, self-reporting of error has missed between 244 and 1000 errors per each error detected by other means.[7] Ideally, all hospitals would conduct an independent audit to determine the validity of their self-reported medication error rate.

Success in JCAHO, CMS, and state licensing surveys may give false assurance that a hospital's medication usage system is not error prone and may not be a basis for confirming that a successful hospital's self-reporting of medication errors is valid.[52]

Identification of bias in self-reporting is integral to the empiricism and statistical models of validation used in contemporary science. Independent validation of experimental observation is a requirement for scientific publication. It should also be a requirement during internal surveillance of complex medication usage systems in hospitals and other psychiatric healthcare settings.

We recommend use of a standardized, empirically validated methodology for medication error detection and reporting in all hospitals. Benchmarks for acceptable medication error rates in inpatient psychiatric settings should be established. Hospital-based psychiatrists need to know a hospital's methodology of error detection, the reported error rates, and current or future performance improvement initiatives that are under way to better detect, report, and rectify errors.

Adopt lexicon of medical terms and definitions. We also believe that psychiatry should adopt the widely accepted lexicon of medical error terms and definitions. Patients would benefit if psychiatrists and their medical and surgical colleagues spoke a common language when detecting, reporting, and managing ADEs. This might also increase awareness among psychiatrists that ADEs include not only ADRs but also medication errors. Broader incorporation of medical error terminology and performance improvement initiatives might also enable a more objective comparison of quality among psychiatric hospitals.

Medication errors of omission. Medication errors of omission occur in circumstances where medication treatment was not given, either because of a missed diagnosis or because of lack of medication access. The latter occurs when formularies are restricted in order to cut costs and/or increase profits. Medicaid, private insurers, and those agencies who will oversee the new 2006 Medicare drug benefit all use formulary restrictions. We believe this area needs further study. One possible strategy for increased reporting of medication errors of omission is the inclusion of medication errors of omission in FDA postmarketing surveillance.

The true costs of insurance. Increasing pressure to cut Medicaid budgets and to maintain or increase shareholders' earnings for private insurers will lead to ongoing attempts at restricting formularies. However, if the reports of Gorman, Lichtenberg, Soumerai, and others are correct, formulary restrictions for Medicaid, Medicare, and privately insured beneficiaries are actually increasing overall healthcare costs.[26-29] Given the cost of medication coverage and pressure on legislators to "do something," it is important to have better cost, safety, and healthcare quality data upon which to base legislative decisions. Matters of cost, safety, and healthcare quality are further complicated by ethics concerns when considering the financial incentive that formulary restrictions pose in the for-profit medical insurance industry -- an industry that posts annual earnings of billions of dollars.

Open reporting should be rewarded, not punished. Fear of punishment may deter the reporting of errors. The establishment of a nonpunitive culture must accompany the incorporation of the mainstream lexicon of medication error terminology and a broader awareness of medical errors in psychiatry. Administrative and clinical leaders are responsible for establishing systems and an ethos that rewards frequent and open reporting of errors and the use of educational review to improve error-prone processes. Inherent in a nonpunitive culture is the recognition that most errors are systems issues and not issues of badly performing individuals. Fear of punishment should not interfere with developments that diminish harm to patients.

JCAHO, CMS, and state licensing surveys could be more successful in detecting error-prone medication usage systems if regulatory standards included the following:

  1. Greater emphasis on measurement of a hospital staff's ability to assess its own error detection and reporting processes, including frequent review of the validity of the self-reported medication error rate

  2. Routine assessment of nursing, pharmacy, and medical staff's understanding of ADEs, ADRs, medication errors, and categories of errors

  3. A more active role by hospital leadership in creating measurable evidence of a nonpunitive culture that rewards error reporting

  4. Universal use of standardized, rigorous medication error criteria. Since primary care clinicians will most likely continue to be the point of entry, and often the sole provider of mental health treatment, for patients suffering from mood and anxiety disorders, improvements in diagnosis and appropriate treatment of these disorders in primary care should be an important priority.

Education of primary care providers. Better education of primary care providers about the symptoms and management of depression and anxiety is essential. Programs designed to increase primary care clinicians' recognition of depression and other psychiatric disorders have not yet proved to improve treatment outcome.[54,55] However, studies that have added training in depression management in addition to education on better recognition of its presence have yielded better outcomes.[56]

The feasibility and sustainability of programs focusing on better education of primary care clinicians has not been established. Because of the time constraints of standard primary care practice, fast and efficient methods of screening, such as the Primary Care Evaluation of Mental Disorders (PRIME-MD) for anxiety, depression, and other psychiatric disorders, are recommended.[36] The Patient Health Questionnaire, a 9-item subset of the PRIME-MD, is a more concise screen for depression, if time constraints preclude use of the full PRIME-MD questionnaire.[57] The routine use of such simple methods for screening and ongoing monitoring might provide a sustainable way of reducing diagnostic errors in ambulatory medical settings.

Incentive programs to improve mental health diagnosis. A final recommendation is for managed care and insurance companies, as well as health systems and provider networks, to consider the implementation of incentives for better detection and treatment of mood and anxiety disorders. Pilot "pay for performance" programs, such as Bridges to Excellence[58] or the Integrated Healthcare Association initiative in California,[59] have focused on physical conditions such as diabetes or asthma. Quality measures do exist for the medication treatment and follow-up of diagnosed depression, such as performance standard and report card measures.[60] Adding incentives for better detection and treatment to the use of quality measures is a recommended first step.

Prevention Strategies

In recent years, considerable progress has been made in developing and researching strategies for decreasing ADEs.[61,62] Specific prevention strategies have been divided into[63]:

  • Short term -- generally lower in cost, more circumscribed in scope, and more quickly and easily implemented

  • Long term -- cost more and are more complex to implement

Two elements are essential as the foundation for successful prevention strategies:

  1. Application of a systems-oriented approach to ADE reduction[64,65]

  2. Promotion of a nonpunitive culture that rewards error reporting[61,66]

Examples of short-term strategies relevant to inpatient psychiatry include the following:

  • The use of medication ordering protocols for drugs that have a narrow therapeutic index and/or might be unsafe to initiate or resume without laboratory data (for example, lithium carbonate, clozapine, carpamazepine, divalproex)

  • The use of unit-dose distribution systems in which medications are individually prepackaged and delivered in the exact dose to the point of administration

  • Access to drug information at the time of prescribing by including a clinical pharmacist in rounds and immediate drug database access using personal digital assistants (PDAs)

  • Nurse and physician orientation and periodic education regarding the prescribing, transcribing, dispensing, and administration process

  • Better patient education in the use of their own medications[63,66,67]

In addition, clinical and pharmacy staff would benefit from systematically monitoring the literature for published reports of preventable adverse events and from reviewing these reports in scheduled multidisciplinary team (such as patient safety team) meetings, which would stimulate performance improvement initiatives directed at further prevention of adverse events. Safety alerts from the JCAHO, the Institute for Safe Medication Practices, the FDA, and others can also be valuable sources of anecdotal reports on patient safety that are not reported in published journals and are not accessible through MEDLINE searches.

Informatics is being used to automate portions of the inpatient medication process by improving checks and controls in pharmacy software systems, incorporating machine-readable coding (bar coding) to ensure that the right drug is administered to the right patient, and preventing prescribing errors by using CPOE.[4,63,67,68] CPOE can dramatically reduce the rates of many types of prescribing errors, such as:

  • Inaccurate dosing

  • Incomplete orders

  • Incorrect routes of administration

  • Illegibility

When utilizing integrated software, the prescriber has current drug information prior to entering an order, including:

  • Dosing

  • Monitoring parameters

  • Potential ADRs

CPOE also provides automated checks for:

  • Allergies

  • Drug interactions

  • Contraindications

CPOE systems can be integrated into other hospital data systems that include patient-specific clinical, demographic, and laboratory data.

There is empirical support for the success of medication error reduction after implementation of CPOE. One study conducted at Brigham and Women's Hospital in Boston demonstrated a 55% decrease in error rates,[11] and serious errors dropped by 88% in a subsequent study by the same group.[69] In another study conducted at LDS Hospital in Salt Lake City, CPOE implementation resulted in a 70% reduction in ADEs.[70]

Limitations of CPOE include:

  • Cost

  • Complexity of installation

  • Integration with existing hospital information management systems

  • Maintenance

  • Prescriber training needs

  • Prescriber resistance

A number of additional computerized interventions appear to have the potential to further decrease medication error rates in the inpatient setting. Among these are[62]:

  • Bar-coding linked to computerized medication administration records

  • "Smart" pumps

  • Automated dispensing devices

  • Pharmacy robots

Within psychiatry, no data are available regarding the efficacy of these technologies, but bar-coding linked to medication administration records would be expected to be especially important given the frequency of use of solid dose forms. Outside the hospital, tools that help patients track what medications they have actually taken may be especially beneficial in this population.

Final Word

We conclude that several approaches are available that should reduce medication error rates in the short term in psychiatry that do not involve automation. Long-term, computerized physician order entry is likely to result in the largest benefit, although this remains to be demonstrated. Bar-coding linked to computerized medication administration records may also be beneficial.

Acknowledgments

The authors gratefully acknowledge the substantial contributions made by Susan Gile, MBA RN.


References

References

  1. Kohn LT, Corrigan JM, Donaldson MS, Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
  2. Crum R. IOM Report Offers Recommendations for Improving Mental Health and Substance Abuse Treatment and Care. November 2006. Available at: http://www.rwjf.org/portfolios/resources/grantsreport.jsp?filename=048021.htm&iaid=131#int_biblio. Accessed February 27, 2007.
  3. Institute of Medicine. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington: National Academy Press, 2006.
  4. Grasso BC, Rothschild JM, Genest R, Bates DW. What do we know about medication errors in inpatient psychiatry? Jt Comm J Qual Saf. 2003;29:391-400.
  5. National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors: What Is a Medication Error? Available at: http://www.nccmerp.org/aboutMedErrors.html. Accessed February 28, 2007.
  6. Identifying and Preventing Medication Errors. Institute of Medicine. Available at: http://www.iom.edu/?id=35942. Accessed February 28, 2007.
  7. Grasso BC, Genest R, Jordan CW, Bates DW. Use of chart and record reviews to detect medication errors in a state psychiatric hospital. Psychiatr Serv. 2003;54:677-681. Abstract
  8. Chyka PA. How many deaths occur annually from adverse drug reactions in the United States? Am J Med. 2000;109:122-130.
  9. Classen DC, Pestotnik SL, Evans RS, Buke JP. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266:2847-2851. Abstract
  10. Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med. 1993; 8:289-294. Abstract
  11. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311-1316. Abstract
  12. Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med. 1997;157:1569-1576. Abstract
  13. Monette J, Gurwitz JH, Avorn J. Epidemiology of adverse drug events in the nursing home setting. Drugs Aging. 1995;7:203-211. Abstract
  14. Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Arch Intern Med. 2000;160:2717-2728. Abstract
  15. Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000;109:87-94. Abstract
  16. Thapa PB, Gideon P, Fought RL, Ray WA. Psychotropic drugs and risk of recurrent falls in ambulatory nursing home residents. Am J Epidemiol. 1995;142:202-211. Abstract
  17. Thapa PB, Gideon P, Cost TW, Milam AB, Ray WA. Antidepressants and the risk of falls among nursing home residents. N Engl J Med. 1998;339:875-882. Abstract
  18. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc. 1999;47:30-39. Abstract
  19. Beers MH, Ouslander JG, Fingold SF, et al. Inappropriate medication prescribing in skilled nursing facilities. Ann Intern Med. 1992;117:684-689. Abstract
  20. Aparasu RR, Fliginger SE. Inappropriate medication prescribing for the elderly by office-based physicians. Ann Pharmacother. 1997;31:823-829. Abstract
  21. Mort JR, Aparasu RR. Prescribing potentially inappropriate psychotropic medications to the ambulatory elderly. Arch Intern Med. 2000;160:2825-2831. Abstract
  22. Senst BL, Achusim LE, Genest RP, et al. Practical approach to determining costs and frequency of adverse drug events in a health care network. Am J Health Syst Pharm. 2001;58:1126-1132. Abstract
  23. Popli AP, Hegarty JD, Siegel AJ, Kando JC, Tohen M. Transfer of psychiatric inpatients to a general hospital due to adverse drug reactions. Psychosomatics. 1997;38:35-37. Abstract
  24. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10:199-205. Abstract
  25. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:307-311. Abstract
  26. Soumerai SB. Unintended outcomes of medicaid drug cost-containment policies on the chronically mentally ill. J Clin Psychiatry. 2003;64(suppl 17):19-22. Abstract
  27. Soumerai SB. Benefits and risks of increasing restrictions on access to costly drugs in Medicaid. Health Aff. 2004;23:135-146.
  28. Lichtenberg FR. New Drugs: Health and Economic Impacts. National Bureau of Economic Research Reporter. Winter 2003. Available at: http://www.nber.org/reporter/winter03/healthandeconomicimpacts.html. Accessed February 28, 2007.
  29. Gorman L. Treatment Denied: State Formularies and Cost Controls Restrict Access to Prescription Drugs. February 2003. Available at: http://www.washingtonpolicy.org/HealthCare/PBGormanTreatmentDenied.html. Accessed February 27, 2007.
  30. National Center for Healthcare Statistics, Fast Facts. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/fastats/mental.htm. Accessed February 28, 2007.
  31. RxList. Top 300 Prescriptions for 2004. Available at: http://www.rxlist.com/top200.htm. Accessed February 28, 2007.
  32. Norquist GS, Regier DA. The epidemiology of psychiatric disorders and the de facto mental health care system. Annu Rev Med. 1996;47:473-479. Abstract
  33. Von Korff M, Shapiro S, Burke JD, et al. Anxiety and depression in a primary care clinic. Comparison of Diagnostic Interview Schedule, General Health Questionnaire, and practitioner assessments. Arch Gen Psychiatry. 1987;44:152-156. Abstract
  34. Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry. 1988;45:1100-1106. Abstract
  35. Allgulander C, Nilsson B. [A nationwide study in primary health care: One out of four patients suffers from anxiety and depression]. Lakartidningen. 2003;100:832-838. Abstract
  36. Spitzer RL, Williams JB, Kroenke K. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994;272:1749-1756. Abstract
  37. Lin EH, Von Korff M, Wagner EH. Identifying suicide potential in primary care. J Gen Intern Med. 1989;4:1-6. Abstract
  38. Foster T, Gillespie K, McClelland R, Patterson C. Risk factors for suicide independent of DSM-III-R Axis I disorder. Case-control psychological autopsy study in Northern Ireland. Br J Psychiatry. 1999;175:175-179. Abstract
  39. Henriksson MM, Aro HM, Marttunen MJ, et al. Mental disorders and comorbidity in suicide. Am J Psychiatry. 1993;150:935-940. Abstract
  40. Foote SM, Etheredge L. Increasing use of new prescription drugs: a case study. Health Aff. 2000;19:165-170.
  41. Wells KB, Sherbourne C, Schenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212-220. Erratum in: JAMA. 2000;283:3204.
  42. Williams JW Jr, Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians' approach to depressive disorders. Effects of physician specialty and practice structure. Arch Fam Med. 1999;8:58-67. Abstract
  43. FDA Public Health Advisory. Suicidality in Children and Adolescents Being Treated With Antidepressant Medications. October 15, 2004. Available at: http://www.fda.gov/cder/drug/antidepressants/SSRIPHA200410.htm. Accessed February 28, 2007.
  44. Curtis LH, Masselink LE, Ostbye T, et al. Prevalence of atypical antipsychotics drug use among commercially insured youths in the United States. Arch Pediatr Adolesc Med. 2005;159:362-366. Abstract
  45. Patel NC, Crismon ML, Hoagwood K, et al. Trends in the use of typical and atypical antipsychotics in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2005;44:548-556. Abstract
  46. FDA Public Health Advisory. Deaths With Antipsychotics in Elderly Patients With Behavioral Disturbances. April 11, 2005. Available at: http://www.fda.gov/cder/drug/advisory/antipsychotics.htm. Accessed February 28, 2007.
  47. Elam L, Murawski MM, Childs S, Vanable JW Jr. Patient safety forum: do state Medicaid preferred drug lists affect patient safety? Psychiatr Serv. 2005;56:1012-1016.
  48. Unutzer J, Klap R, Sturm R, et al. Mental disorders and the use of alternative medicine: results from a national survey. Am J Psychiatry. 2000;157:1851-1857. Abstract
  49. Matthews SC, Camacho A, Lawson K, Dimsdale JE. Use of herbal medications among 200 psychiatric outpatients: prevalence, patterns of use, and potential dangers. Gen Hosp Psychiatry. 2003;25:24-26. Abstract
  50. Knaudt PR, Connor KM, Weisler RH, Churchill LE, Davidson JR. Alternative therapy use by psychiatric outpatients. J Nerv Ment Dis. 1999;187:692-695. Abstract
  51. Grasso BC, Rothschild JM, Jordan CW, Jayaram G. What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyor. J Psychiatr Pract. 2005;11:268-273. Abstract
  52. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162:1897-1903. Abstract
  53. Herzog A, Shore MF, Beale RA, et al. Patient Safety and Psychiatry: Recommendations to the Board of Trustees of the American Psychiatric Association. February 10, 2003 version. January Available at: http://www.psych.org/edu/other_res/lib_archives/archives/tfr/tfr200301.pdf. Accessed April 20, 2007.
  54. Dowrick C. Does testing for depression influence diagnosis or management by general practitioners? Fam Pract. 1995;12:461-465. Abstract
  55. Reifler DR, Kessler HS, Bernhard EJ, Leon AC, Martin GJ. Impact of screening for mental health concerns on health service utilization and functional status in primary care patients. Arch Intern Med. 1996;156:2593-2599. Abstract
  56. Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA. 2003;289:3145-3151. Abstract
  57. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282:1737-1744. Abstract
  58. Bridges to Excellence: Rewarding Quality Across The Healthcare System. Available at: http://www.bridgestoexcellence.org. Accessed February 28, 2007.
  59. The Integrated Healthcare Association. Available at: http://www.iha.org. Accessed February 28, 2007.
  60. NCQA's Report Card for Managed Behavioral Healthcare Organizations. Available at: http://hprc.ncqa.org/mbho/index.asp. Accessed March 1, 2007.
  61. Cullen DJ, Bates DW, Leape LL. Prevention of adverse drug events: a decade of progress in patient safety. J Clin Anesth. 2000;12:600-614. Abstract
  62. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348:2526-2534. Abstract
  63. Massachusetts Coalition for the Prevention of Medical Errors. MHA Best Practice Recommendations to Reduce Medication Errors: Executive Summary. Available at: http://www.macoalition.org/documents/Best_Practice_Medication_Errors.pdf. Accessed April 20, 2007.
  64. Grasha AF. Into the abyss: seven principles for identifying the causes of and preventing human error in complex systems. Am J Health Syst Pharm. 2000;57:554-564. Abstract
  65. Leape LL. Error in medicine. JAMA. 1994;272:1851-1857. Abstract
  66. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995; 274:35-43. Abstract
  67. American Society for Healthcare Pharmacists. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993;50:305-314. Abstract
  68. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997; 277:301-306. Abstract
  69. Bates DW, Teich JM, Lee J, et al. The impact of computerized prescriber order entry on medication error prevention. J Am Med Informatics Assoc. 1999;6:313-321.
  70. Evans RS, Pestotnik SL, Classen DC, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med. 1998;338:232-238. Abstract