Add To Cart


Section 2
Medication Error in Mental Health: Implications for Primary Care

Question 2 | Test | Table of Contents

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 errors, one of the most frequent clinical errors, are estimated to cause 7000 deaths every year in the USA and occur in between 2% and 15% of UK hospital admissions[4–6] Medication errors are associated with significant costs and morbidity (1–2% of hospital inpatients are harmed by a medication error).[3,7,8] 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]

In the USA over half and in the UK between 30% and 50% of people with a mental health problem only receive treatment from primary care services.[12,13] The continuity of care and the physical health care available within primary care are particularly important.[14]

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 clinicians may not be aware of medication supplied by secondary care colleagues, resulting in unintended drug interaction.[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, community pharmacy and community mental health teams) are potentially involved. A study within a mental health trust found that discrepancies in the medication record in the medical notes occurred in 69% of discharges and 43% of admissions, and of these 24% and 18%, respectively were judged to be potentially harmful.[23] Research on medicine reconciliation is a priority, and should focus on potentially high-risk groups, such as mental health patients.[25,26]

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-linemental 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 and people with mental health problems maybe 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 not identify an error this view may ignored due to capacity concerns. [38]

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] Carers may lack access to appropriate professional advice in relation to medication management and frequently report problems with medication management activities related to making judgments as to whether treatment is appropriate and managing side effects. [40, 43]

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]

Role of Trust
            Trust has a central role in health care particularly in diseases characterized by uncertainty and vulnerability, such as mental health disorders. [44] Trust between service users and healthcare professionals is vital in supporting patient safety, reducing errors and improving adherence to psychotropic medication. [45-49] Rates of adherence may be three times lower where there are very low levels of trust, with potentially severe societal consequences in terms of serious untoward incidents, such as suicide and homicide, which regularly attract media attention. [46, 50]

            Clinicians may not supply complete information about adverse events, due to fears about the potential impact on adherence. [38] Patients who are not warned about a particular adverse event may not know how to manage it, or that urgent treatment is required. [18, 53] Sectioning, when treatment is legally enforced, may impact on patient safety due to erosion of trust. [38] Clinicians may be less likely to believe safety concerns expressed by a sectioned patient, potentially resulting in a medication error; however, empirical evidence is currently lacking. [38]

            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 error in primary care.  Write one case study example regarding how you might use the content of this section in your practice.
Reviewed 2023

Impact of a clinical pharmacist on medication safety in mental health Hospital-in-the-Home:
a retrospective analysis

Farag, M., Hoti, K., Hughes, J., & Chalmers, L. (2022). Impact of a clinical pharmacist on medication safety in mental health Hospital-in-the-Home: a retrospective analysis. International journal of clinical pharmacy, 44(4), 947–955.

Peer-Reviewed Journal Article References:
Gallimore, C. E., Sokhal, D., Zeidler Schreiter, E., & Margolis, A. R. (2016). Pharmacist medication reviews to improve safety monitoring in primary care patients. Families, Systems, & Health, 34(2), 104–113. 

Halfond, R. W., Wright, C. V., & Bufka, L. F. (2021). The role of harms and burdens in clinical practice guidelines: Lessons learned from the American Psychological Association's guideline development. Clinical Psychology: Science and Practice, 28(1), 19–28.

Shahidullah, J. D., Hostutler, C. A., & Forman, S. G. (2019). Ethical considerations in medication-related roles for pediatric primary care psychologists. Clinical Practice in Pediatric Psychology, 7(4), 405–416.

Shahidullah, J. D., Hostutler, C. A., & Stancin, T. (2018). Collaborative medication-related roles for pediatric primary care psychologists. Clinical Practice in Pediatric Psychology, 6(1), 61–72. 

What is Transitional Care? To select and enter your answer go to Test

Section 3
Table of Contents

Excerpt of Bibliography mentioned above
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.
PublicationsPolicyAndGuidance/DH_4006376 (accessed 3 June 2009).
8 Franklin B, Schachter M, Vincent C et al. The incidence of prescribing errors in hospital in-patients. Drug Safety 2005;28:891–900.
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.
12 Jenkins R, McCulloch A, Friedli L et al. Developing a national mental health policy. London: Maudsley Monograph, 2002.
13 Norquist GC and Regier DA. The epidemiology of psychiatric disorders and the de facto mental health care system. Annual Reviewof Medicine 1996;47:473–9.
14 Lester HE, Tritter JQ and Sorohan H. Patients’ and health professionals’ views on primary care for people with serious mental illness: focus group study. BMJ 2005;330:1122.
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.
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. (accessed 2 April 2009).
22 Department of Health. The NHS Plan: a plan for investment a plan for reform. London: Department of Health, 2000. (accessed 24 May 2006).
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.
26 National Institute for Clinical Excellence. Draft Scope on the Clinical and Cost-effectiveness of Systems Based and IT Based Interventions in Medicines Reconciliation. 2007. (accessed 16 May 2007).
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. ActaPsychiatrica 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.
34 Maidment ID, Fox C, ElswoodMet al. An Analysis of Medication Related Incidents (Errors or Potential Errors) in Older People Reported from Mental Health Trusts in a Sample from the NPSA Reporting and Learning System (RLS). Presented at 19th IAGG World Congress of Gerontology and Geriatrics, IAAG 2009.
35 National Patient Safety Agency. Safety in Doses: learning from national reporting 2007. NPSA, 2009. Available at: (accessed 29/12/09).
36 Warner B and Gerrett D. Identification of medication errors through community pharmacies. International Journal of Pharmacy Practice 2005;13:1–6.
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.
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.
44 Hall MA, Dugan E, Zheng B et al. Trust in physicians and medical institutions: what is it, can it be measured and does it matter. The Milbank Quarterly 2001;79:613–39.
46 Altice FL, Mostashari F and Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndrome 2001;28:47–58.
50 Safran DG, Taira DA, Rogers WH et al. Linking primary care performance to outcomes of care. The Journal of Family Practice 1998;47:213–20.
53 EMERGE (Erice Medication Errors Research Group). Medication errors: problems and recommendations from a consensus meeting. British Journal of Clinical Pharmacology 2009;67:592–8.