ABSTRACT

Prescribing errors are common in mental health settings and a significant number of these errors may result in a serious outcome. In the majority of cases, simple steps such as reduced junior doctor workload, improved training in psychopharmacology and more direct supervision of prescribing may have prevented the error. These are systems problems that are easy to detect, but difficult to address. The contribution of clinical pharmacists in detecting errors before they have a (sometimes serious) clinical impact should not be underestimated. Research on medication error in mental health care is limited. A review of the various studies done in relation to prescription errors is undertaken by us to understand this multifactorial and serious problem. Most of the research that is available is focused on secondary care; most studies have only included in patients and mainly relate to prescribing. All the studies are process based, rather than outcome based, and there has been no systematic study of causes of medication error in mental health care associated with deficits in knowledge or decision-making. The studies report few errors that result in actual serious harm to the patient. Hence, we decided to look at the various studies and attempt a comprehensive review of the topic. Adverse events involving psychotropic drugs are common and some may be due to errors in clinical decision making of a type not detected by the studies reviewed. These are potentially preventable. On the basis of this, it is recommended that medicine management in mental health settings should be a priority for future research.

KEY WORDS: Prescription errors; Health care; Medication