Understanding the causes of preventable medication incidents for patients with mental illness in primary care
Authors: Ayre M J , Lewis P J , Phipps D L , Keers R N 
Published: November 2023

Abstract

Introduction
A recent scoping review has highlighted that whilst patients with mental illness are commonly affected by medication errors and preventable adverse drug events in primary care, there were limited data regarding their causes1. By understanding why these preventable events occur, targeted interventions can be developed.

Aim
To understand the nature and contributory factors that lead to medication errors and preventable adverse drug events amongst patients with mental illness in primary care.

Methods
This study used a qualitative design. A researcher remotely interviewed 26 healthcare professionals (14 pharmacists, 5 GPs, 5 nurses, 2 psychiatrists) working in primary care between June-November 2022, guided by the critical incident technique. Professionals were recruited via social media, research team networks, and snowballing. Data were analysed using the framework method and any data that involved speculation as to the causes of errors was not included. The data were organised into themes based on the London protocol error framework, which describes the contributory factors leading to care delivery problems2. Themes generated were validated by other members of the research team and a patient advisory group. This study was approved by the University of Manchester Ethics Committee 1 (reference 2022-13735-23555).

Results
Forty-three medication errors and twelve preventable adverse drug events were discussed during interview. Prescribing errors were discussed most commonly (n=24) and administration errors least commonly (n=4). Six contributory factors were identified which were: the individual (staff) (n=37); the work environment (n=31); the teams/interfaces (n=28); the organisation and management (n=24); the patient (n=23); and the task and technology (n=15). Primary care clinicians reported a lack of knowledge regarding psychotropics and mental illness which accompanied diffusion of responsibility. The responsibilities of staff were also confused by limited clinical information communicated between teams and across care interfaces. Service demand was reported to exceed capacity, creating stress for the staff, as well as limiting the time available for staff to undergo training. Complicated patient lifestyles and behavioural challenges were reported as unique contributory factors.

Discussion/Conclusion
Lack of knowledge amongst primary care clinicians regarding psychotropics and mental illness was a key issue. This was exacerbated by a mental health service structure placing considerable pressure on primary care leaving clinicians to support patients with needs perceived to be outside their areas of confidence and competence. There is a need to support this workforce by upskilling them to effectively manage patients by addressing the educational needs regarding neuropharmacology and communication skills. These changes may have a positive effect in reducing error rates for this patient group in primary care. Study limitations include recall bias, social desirability bias, as well as the majority errors discussed were made by another clinician within a chain therefore critical details may be missing in the series of events. This is the first study to identify the nature and contributory factors of preventable medication incidents for patients with mental illness in primary care. Future research should focus on exploring this topic from the perspective of patients to better understand the causes of preventable medication incidents.

References
1. Ayre M, Lewis P, Keers R. Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review. BMC Psychiatry. 2023;In Press.
2. Taylor-Adams S, Vincent C. Systems analysis of clinical incidents: the London protocol. Clinical Risk. 2004;10(6):211-20.