2021_Book_TextbookOfPatientSafetyAndClin

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given at doses that are typically used in humans
for diagnosis, prevention or modification of
physiological functions. These reactions result in
increased mortality, morbidity, cost of treatment
and non-adherence to treatment [21]. ADRs pose
a significant problem in the treatment of patients
with mental illness because these patients often
lack adequate insight into their condition and
treatment, and the ADR further complicates the
situation [23]. Weight gain, constipation and
tremors are among the most common ADRs that
have been reported [21].
ADRs in psychiatry units are common and
somewhat preventable. Rothschild et al. reported
that 13% of all ADRs were preventable and atypical
antipsychotics accounted for 37% of reported
ADRs [22]. A study on the referrals of psychiatric
inpatients to general hospitals found out that
76% of transfers were because of neurological
reactions and 32% of transfers were because of
the use of more than one psychotropic drug [23].
Studies conducted in New England and
Kolkata, India, found that atypical antipsychotics
were responsible for the majority of the ADRs
reported in psychiatry units [21]. Thomas et al.
conducted a study that involved the analysis and
evaluation of ADRs reported in a psychiatric hospital
for 3 years. The study found that the most
frequent drugs associated with ADRs were antiepileptics,
cardiovascular agents and secondgeneration
antipsychotics. The study also found a
20.4% ADR preventability rate in the mental care
units, which is lower than the preventability rates
found in general inpatients and long-term facilities
[24].
20.3 Medical Errors
in Psychiatric Care
A. Cuomo et al.
As in the general medical setting, medical errors
in psychiatric care lead to significant injuries, up
to death, as well as to an increase in the healthcare
system costs.
Medical errors are classified into diagnostic
errors, preventive errors, treatment errors and
‘other errors’. Diagnostic failure includes failure
to diagnose, including failure to order a diagnostic
test. Preventive errors include failure in preventing
disease or in monitoring the disease
processes. Treatment errors include failure in
providing medical interventions. Other errors
include system error caused by a failure in the
operating system or defective medical
equipment.
The chain of events that leads to medical error
is complex, but factors that lead to errors can be
broadly classified as patient factors, provider factors
and system factors.
(a) Patient Factors
Acute psychiatric symptoms such as
impulsive, homicidal, suicidal and poorjudgement
behaviour could result in either
mistakes or slips. Mistakes include inaccurate
treatment plans, whereas slips result
from the deviation from the action plan.
Psychiatric patients may not be able to accurately
report their symptoms to the physician,
which may delay treatment and complicate
the differential diagnosis of diseases. Violent
patients may induce distress and interfere
with the decision-making process. For
instance, even providers who are well knowledgeable
of the dosing guidelines may end
up administering excessive doses to these
patients [25].
(b) Provider Factors
Mental healthcare providers have a considerable
effect on patient safety [4].
Workplace stress and mental workload of the
staff may impact on patients’ safety and
treatment. Communication deficiency is a
commonly observed contributor to errors in
psychiatry units [26]. Factors that may affect
communication include fatigue, high staff
turnover, lack of experience and interpersonal
conflict [4]. Decreased length of stay
by medical personnel in psychiatry units
could raise the chances of missing out on
crucial clinical information, such as medical
comorbidities, medication allergies or medication
dosing errors. The fear of aggression
may result in an increased use of seclusion or
restraint, as well as in insufficient therapeutic
engagement [27].