Identifying and reducing medication errors in psychiatry: Creating a culture of safety through the use of an adverse event reporting mechanism

Research output: Contribution to journalArticle

Abstract

Medication errors (MEs) in psychiatry have not been extensively studied. No long-term prospective efforts to demonstrate error reduction in psychiatric care using multidisciplinary interventions have been published in the literature. This article discusses the implementation of the Patient Safety Net (PSN) (an error reporting system) and of the Provider Order Entry (POE) program (a prescribing system). We educated and trained staff in their use, conducted concurrent chart reviews to estimate true error reduction, and provided continuous feedback as errors occurred. The intervention described here resulted in a reduction in MEs in association with performance improvement efforts that were conducted over 5 years and involved 65,466 patient days, and 617,524 billed doses, which is the largest study of an intervention to reduce psychiatric medication errors reported to date.

Original languageEnglish (US)
Pages (from-to)81-88
Number of pages8
JournalJournal of Psychiatric Practice
Volume17
Issue number2
DOIs
StatePublished - Mar 2011

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Safety Management
Medication Errors
Psychiatry
Concurrent Review
Patient Safety

Keywords

  • adverse events
  • computerized order entry
  • harm scores
  • inpatient
  • medication errors
  • patient safety
  • psychiatry

ASJC Scopus subject areas

  • Psychiatry and Mental health

Cite this

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abstract = "Medication errors (MEs) in psychiatry have not been extensively studied. No long-term prospective efforts to demonstrate error reduction in psychiatric care using multidisciplinary interventions have been published in the literature. This article discusses the implementation of the Patient Safety Net (PSN) (an error reporting system) and of the Provider Order Entry (POE) program (a prescribing system). We educated and trained staff in their use, conducted concurrent chart reviews to estimate true error reduction, and provided continuous feedback as errors occurred. The intervention described here resulted in a reduction in MEs in association with performance improvement efforts that were conducted over 5 years and involved 65,466 patient days, and 617,524 billed doses, which is the largest study of an intervention to reduce psychiatric medication errors reported to date.",
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