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Martin K, Bickle K, Lok J. Int J Mental Health Nurs. 2022;Epub Mar 30.
Cognitive biases can compromise decision making and contribute to poor care. In this study, nurses were provided two patient vignettes as well as associated clinical notes written using either biased or neutral language and asked to make clinical decisions regarding PRN (“as needed”) medication administration for sleep. The study identified a relationship between biased language and clinical decision-making (such as omitting patient education when administering PRN medications).
Alshehri GH, Ashcroft DM, Nguyen J, et al. Drug Saf. 2021;44:877-888.
Adverse drug events (ADE) can occur in any healthcare setting. Using retrospective record review from three mental health hospitals, clinical pharmacists confirmed that ADEs were common, and that nearly one-fifth of those were considered preventable.
Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17:341-351.
Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.
Sharma AE, Yang J, Del Rosario JB, et al. Jt Comm J Qual Patient Saf. 2021;47:5-14.
Ambulatory care settings are receiving increased attention as a focus for patient safety improvements. Using data from a multistate patient safety organization (PSO) database, the researchers sought to characterize patterns and characteristics of patient safety incidents reported in ambulatory care settings. Analyses found that 5.9% of events resulted in severe harm and 1.9% resulted in patient death. Over half of the events were from outpatient subspecialty care; fewer events occurred in home/community (5.2%), primary care (2.1%), or dialysis (2.0%) settings. Medication-related events were most common, followed by clinical deterioration and falls. Predictors of higher harm included diagnostic errors, patient/caregiver challenges, and events occurring in home/community or psychiatric settings. These results can help ambulatory care settings target safety events and develop systems-level prevention strategies.  
Cullen SW, Xie M, Vermeulen JM, et al. Med Care. 2019;57:913-920.
Various factors can impact patient safety risk in psychiatric settings. This study assessed the prevalence of AEs and MEs in community hospitals and Veterans Health Administration (VHA) hospitals and found that psychiatric inpatients at community hospitals were twice as likely to experience these patient safety events than VHA inpatients, even after controlling for patient and hospital characteristics.

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Keers RN, Plácido M, Bennett K, et al. PLoS One. 2018;13:e0206233.
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.
Sulkers H, Tajirian T, Paterson J, et al. JAMIA Open. 2019;2:35–39.
Electronic health records (EHRs) have been widely adopted as a strategy to improve patient safety. This commentary explores how one hospital used professional standard achievement to motivate medication safety in inpatient mental health settings. The innovation emphasized scanning technologies, direct prescriber order entry, and EHR-generated data analysis as approaches to enhance the reliability of medication processes for this patient base.
Keers RN, Williams SD, Vattakatuchery JJ, et al. J Clin Pharm Ther. 2015;40:645-54.
In this study, prospective pharmacist review of written prescriptions for adults discharged from mental health hospitals found that about 20% contained medication errors. These findings underscore the risks of adverse events in the postdischarge period and the need for more oversight of discharge prescriptions.
Cottney A, Innes J. Int J Ment Health Nurs. 2015;24:65-74.
In this prospective observational study at a psychiatric hospital, errors were identified in 3% of medication administration episodes, with omission being the most common error type. As in prior studies, interruptions and higher patient volume were associated with increased risk of mistakes.
Haw C, Stubbs J, Dickens GL. J Psychiatr Ment Health Nurs. 2014;21:797-805.
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.
Kelly T, Roper C, Elsom S, et al. Int J Ment Health Nurs. 2011;20:371-9.
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.
Jayaram G, Doyle D, Steinwachs D, et al. J Psychiatr Pract. 2011;17:81-8.
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.
A man prescribed a tricyclic antidepressant and an antipsychotic medication was found unconscious and unresponsive at home and was brought to the emergency department (ED). An electrocardiogram showed potentially dangerous heart rhythms.
Cullen SW, Nath SB, Marcus SC. Psychiatr Q. 2010;81:197-205.
The authors used focus groups and interviews to develop a taxonomy of errors in inpatient psychiatry and explore underlying systems causes of the errors. Medication errors, diagnostic errors, and failure to prevent patient harm (such as suicide attempts) were among the common types of errors identified.
London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.
This publication analyzes 72,482 medication incidents reported to the National Health Service and highlights areas for improvement and prevention.