Medicines reconciliation in comparison with NICE guidelines across secondary care mental health organisations

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: A multi-centre study

Objective

Limited evidence concerning the burden and predictors of omitted medication doses within mental health hospitals could severely limit improvement efforts in this specialist setting. This study aimed to determine the prevalence, nature and predictors of omitted medication doses affecting hospital inpatients in two English National Health Service (NHS) mental health trusts.

Methods

Over 6 data collection days trained pharmacy teams screened inpatient prescription charts for scheduled and omitted medication doses within 27 adult and elderly wards across 9 psychiatric hospitals. Data were collected for inpatients admitted up to two weeks prior to each data collection day. Omitted doses were classified as ‘time critical’ and ‘preventable’ based on established criteria. Omitted dose frequencies were presented with 95% confidence intervals (CI). Multilevel logistic regression analyses determined the predictors of omitted dose occurrence, with omission risks presented as adjusted odds ratios (OR) with 95% CI.

Results

18,664 scheduled medication doses were screened for 444 inpatients and 2,717 omissions were identified, resulting in a rate of 14.6% (95% CI 14.1–15.1). The rate of ‘time critical’ omitted doses was 19.3% (95% CI 16.3–22.6%). ‘Preventable’ omitted doses comprised one third of all omissions (34.5%, 930/2694). Logistic regression analysis revealed that medicines affecting the central nervous system were 55% less likely to be omitted compared to all other medication classes (9.9% vs. 18.8%, OR 0.45 (0.40–0.52)) and that scheduled doses administered using non-oral routes were more likely to be omitted compared the oral route (inhaled OR 3.47 (2.64–4.57), topical 2.71 (2.11–3.46), ‘other’ 2.15 (1.19–3.90)). ‘Preventable’ dose omissions were more than twice as likely to occur for ‘time critical’ medications than non-time critical medications (50.4% vs. 33.8%, OR 2.24 (1.22–4.11)).

Conclusions

Omitted medication doses occur commonly in mental health hospitals with ‘preventable’ omissions a key contributor to this burden. Important targets for remedial intervention have been identified.

Frequency and Nature of Medication Errors and Adverse Drug Events in Mental Health Hospitals: a Systematic Review

INTRODUCTION

Little is known about the frequency and nature of medication errors (MEs) and adverse drug events (ADEs) that occur in mental health hospitals.

OBJECTIVES

This systematic review aims to provide an up-to-date and critical appraisal of the epidemiology and nature of MEs and ADEs in this setting.

METHOD

Ten electronic databases were searched, including MEDLINE, Embase, CINAHL, International Pharmaceutical Abstracts, PsycINFO, Scopus, British Nursing Index, ASSIA, Web of Science, and Cochrane Database of Systematic Reviews (1999 to October 2016). Studies that examined the rate of MEs or ADEs in mental health hospitals were included, and quality appraisal of the included studies was conducted.

RESULT

In total, 20 studies were identified. The rate of MEs ranged from 10.6 to 17.5 per 1000 patient-days (n = 2) and of ADEs from 10.0 to 42.0 per 1000 patient-days (n = 2) with 13.0-17.3% of ADEs found to be preventable. ADEs were rated as clinically significant (66.0-71.0%), serious (28.0-31.0%), or life threatening (1.4-2.0%). Prescribing errors occurred in 4.5-6.3% of newly written or omitted prescription items (n = 3); dispensing errors occurred in 4.6% of opportunities for error (n = 1) and in 8.8% of patients (n = 1); and medication administration errors occurred in 3.3-48.0% of opportunities for error (n = 5). MEs and ADEs were frequently associated with psychotropics, with atypical antipsychotic drugs commonly involved. Variability in study setting and data collection methods limited direct comparisons between studies.

CONCLUSION

Medication errors occur frequently in mental health hospitals and are associated with risk of patient harm. Effective interventions are needed to target these events and improve patient safety.

Training healthcare professionals in quality improvement

The Academy of Medical Royal College's report Quality improvement - training for better outcomes sets a path for the normalisation of quality improvement as part of all health professionals' jobs. This accompanies similar calls to action by the King's Fund and the Faculty of Medical Leadership and Management and is aligned with NHS Improvement and Health Education England future strategies. These exhortations to action come on the backdrop of increased fiscal constraints within the NHS, low morale, a burgeoning volume of research evidence and audit outputs and increasing complexity of how we deliver care in a bewildering NHS landscape. Asking the question 'how can we do something better?' or 'do we really need to do this?', and building our resilience and capability to respond effectively gives us new purpose, the right skills and a means to influence and make a difference to the safety, -effectiveness and experience of patient care. Most importantly, we do this through harnessing the talents of -multiprofessional teams - with meaningful patient involvement - to rediscover the joy and optimism in our work and what truly motivates us and to see this translated into improved sustainable outcomes for our patients and our working days.