Medication errors in mental healthcare: a systematic review

Area of Science:

• Pharmacovigilance
• Mental Health Services Research
• Patient Safety

Background:

• Medication errors affect 1-2% of general hospital patients.
• No prior systematic review existed for medication errors in mental healthcare settings.
• Limited understanding of medication error incidence, causes, and types in mental health services.

Purpose of the Study:

• To systematically review the literature on medication error incidence and causes within mental healthcare.
• To examine medication management processes in community and hospital-based mental healthcare.
• To identify gaps in current research regarding medication errors in mental health.

Main Methods:

• Systematic literature search for studies on medication error in mental healthcare.
• Analysis of studies examining medication management processes (not outcomes).
• Evaluation of error rates based on study design and reporting methods (drug charts, pharmacist reports, incident systems).

Main Results:

• Error rates varied significantly by detection method: highest with drug chart review, intermediate with pharmacist reporting, lowest with incident reporting systems.
• Most identified medication errors did not result in patient harm, often due to early detection and intervention.
• Research predominantly focused on inpatients and prescriptions handled by mental health pharmacists.

Conclusions:

• Significant gaps exist in research on medication errors within mental healthcare, particularly in non-hospital settings and the resulting harm.
• Psychotropic medications contribute to preventable adverse drug events, likely due to medication errors.
• Future research priorities should address the limited data and organizational factors in mental healthcare that may increase medication error risk.