Prescription errors in psychiatry - a multi-centre study
Jean Stubbs1,
Camilla Haw1,
David Taylor2*
1 St Andrew's Hospital, Northampton, UK
2 Maudsley Hospital, London, UK
* To whom correspondence should be addressed.
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Abstract |
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Medication errors are an important cause of patient morbidity and mortality, of
which there have been few reports in psychiatry, especially in the UK. Our aim was to
examine the nature, frequency and potential severity of prescribing errors in UK mental
health units in a prospective, 1 week survey of errors detected by pharmacy staff in
nine NHS trusts. Pharmacists checked 22 036 prescription items. In total, 523 errors
meeting the study definition were detected (2.4% of prescription items checked).
Prescription writing errors (77.4%) were most common, while decision-making errors
accounted for 22.6% of errors. In 280 (53.5%) cases the prescribed drug had been
administered before the error was detected. Most errors were of doubtful or minor
importance but 22 (4.3%) were deemed likely to result in serious adverse effects or
death. The error detection rate varied fourfold between trusts. Prescribing errors are
fairly common in psychiatry. A small proportion of errors have the potential for serious
harm. Pharmacy staff have an important role to play in their management.
Key Words:
prescribing, error, psychiatry, pharmacist
