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Medication errors on admission to Mental Health Units

Medical research

15 November 2013  

A recent study, published in the International Journal of Clinical Pharmacy, involving Aston University, South Essex Partnership University NHS Foundation Trust (SEPT) and the University of East Anglia found medication errors were common on admission to mental health services.

The study, found that medication errors occurred in 212 of 377 (56.2%) of patients admitted to the assessment ward, between March to June 2012. The errors were corrected by a simple pharmacy led intervention, undertaken by the Trust’s own dedicated pharmacy service. The researchers found that if these errors had not been corrected over three-quarters of patients would have been exposed to moderate harm. The errors involved various medicines, including anti-psychotics, heart medicines and medicines for diabetes, which are used to treat a range of diseases including Alzheimer’s disease, schizophrenia and bipolar disorder (previously called manic depression). 

We found that medication errors may affect over half of patients admitted to NHS Mental Health Services

Ian Maidment, Senior Lecturer in Clinical Pharmacy at Aston University, who supervised the research, said; “We found that medication errors may affect over half of patients admitted to NHS Mental Health Services. These errors were corrected by a simple pharmacy-led intervention. SEPT have a “gold standard” dedicated pharmacy service, which aims to review the medication for every admission, and stop errors from reaching the patient and causing harm. Worryingly, we don’t know how widespread such services are and recent national reports have identified a lack of Pharmacy Services in Mental Health.”  

Hilary Scott, Chief Pharmacist at SEPT said; “We introduced pharmacy-led medicines reconciliation when pharmacy services in Essex were brought in-house in April 2010. This forms an important aspect of our clinical pharmacy service with almost all admissions to the mental health assessment unit benefiting from the service. This means that there is a higher probability that the medicines prescribed on admission correspond with those that the patient was taking before admission, minimizing the risks associated with medication errors which commonly occur when a patient transfers from one care setting to another.”    

Dr Chris Fox, one of the researchers and a Senior Clinical Lecturer at the UEA (University of East Anglia)’s Norwich Medical School commented; “As a medic I am very concerned that these errors could have caused real harm and demonstrate the importance of a pro-active multi-disciplinary approach to medication management.” 

Ian Maidment added; “It is important to keep taking your medication as usual, even if you are concerned that there may have been an error. If you have any concerns please talk to your doctor or pharmacist.” He also highlighted the need for more research; “This project only studied errors when people were admitted to secondary care mental health services and less is known about the risk of such errors when patients move from secondary care to primary care. We need much more research on the frequency, and ways to reduce, these types of errors.”  

For further information on the project or to arrange an interview with Ian Maidment contact 0788 798 3117. 

The study is available to read online here.

Technical Notes

  1. This prospective evaluation was undertaken at the Basildon Assessment Unit in South Essex from March to June 2012 
  2. People aged over 18 living within South Essex, who develop severe mental health problems and people with mental health problems in crisis requiring in-patient admission, would be routinely admitted to the assessment unit.  
  3. The errors involved a range of medicines most commonly anti-depressants (in 111 cases), anti-psychotics (in 74 cases) and medicines for various forms of heart disease (in 63 cases).