Medication reconciliation can help identify medication discrepancies during transitions of care. This study examined the impact of a complete medication history database to support pharmacist-led medication reconciliation and identification of medication discrepancies during the admission process for patients at one psychiatric hospital. A retrospective analysis identified 82 medication errors; 90% of these errors – primarily dosage discrepancies and omissions – could have led to patient harm if not corrected through pharmacist intervention.

This interview study used a human factors method, the critical incident technique, to identify underlying factors in medication administration errors in a mental health inpatient facility. The team identified multiple interconnected vulnerabilities, including inadequate staffing, interruptions, and communication challenges. The findings underscore the persistence of widely documented medication safety administration concerns.

Effective apology behaviors improve opportunities for error resolution for clinicians, patients, and families. This commentary highlights the importance of expressing empathy, considering legal implications, and demonstrating individual, leadership, and organizational support of open disclosure.

Medication errors are common in mental health care. This survey of nurses and nursing students identified interruptions and insufficient medication knowledge as major barriers to ensuring medication safety in outpatient mental health.

Researchers interviewed mental health nurses to determine perceived obstacles to reporting medication administration errors or near misses. Many factors were identified, including insufficient knowledge, fear of consequences, or burden of work associated with reporting. These have also been cited as reasons for under-reporting of errors in prior nursing studies.

This study used focus groups to identify safety concerns voiced by inpatients on a psychiatric unit. Patients primarily expressed concern for their physical safety and expected nurses to ensure it.

This qualitative study demonstrated marked similarities between nurse and consumer perspectives for safe patient identification. Technical aids, such as wristbands and photographs, were deemed important but not replacements for the nurse–patient encounter.

Adverse drug events have been documented as a significant problem in inpatient psychiatric facilities, but methods of preventing errors in this setting have not been researched. This study, conducted at an academic inpatient psychiatric hospital, combined a computerized provider order entry system with a structured event reporting system that was used by physicians, nurses, and pharmacists. Implementation of the system was associated with a significant reduction in both prescribing errors and medication administration errors over a 5-year period.

The researchers observed clinical staff administering medications in an elderly psychiatric patient population and saw that errors were common yet rarely of serious clinical consequence.

The authors analyzed the incidence and type of medication errors and adverse drug events in a psychiatric hospital. They found that errors were common in this setting and were frequently associated with physician orders.

The authors analyzed untoward events in psychiatric wards and found them more likely to coincide with a high male patient population, staff absences, and the occurrence of other incidents.

The investigators analyzed incident reports from a 42-month period and found that both environmental and personal factors played a key role in the medication errors and near misses reported.

The authors analyzed incident reports from Japanese long-term care psychiatric units to understand the relationship between environmental, organizational, and human factors elements of drug administration and how they affect the interception of errors.