UnDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in primaRy care (DISCOVER): a qualitative study

Matthew Ayre, The University of Manchester

This project aims to understand why mistakes with medication (medication errors) happen and the harm they may cause patients with mental illness in the community. In mental health hospitals the causes of these mistakes are well understood, and efforts are now moving towards developing new approaches to improve medication safety. However, less is known about why these issues occur in the community for those with mental illness which makes it difficult to plan improvement efforts that have the best chance of working. We know that medication errors commonly affect patients with various types of health problems in the community, and as the majority of patients with mental illness are cared for entirely in the community the risks to patients from these errors could be high. National and international organisations have acknowledged this global challenge and have recently set goals to try and improve medication safety particularly for patients with mental illness. 
The need for this project started with a review of published studies to highlight what we currently know about medication safety issues for patients with mental illness in the community. The review found that there was very little in these published studies about medication errors made by healthcare professionals and the harm they cause, with most of what is known concerning the problems patients experience when taking their own medicines. It is now critically important to understand more about the causes of medication errors as we can do something to prevent them, and this information will help us develop ways to improve health care services and reduce patient harm from medicines. 
The project will involve talking to healthcare professionals working in UK community settings (e.g. general practice, community pharmacy, community mental health teams etc.) about one or more medication error(s) (prescribing, monitoring, dispensing, or administration) and/or patient harm caused and explore the reasons why this happened. The researcher will also ask these professionals to discuss ways in which they think the error could have been prevented. A human error framework will help explore and understand the findings allowing recommendations for improvements to be made. These recommendations could help provide foundational knowledge to help develop new ways to improve medication safety for patients with mental illness in primary care. The project plan has been presented to a patient and public advisory board to gather patient insight to ensure the methods address patient needs and explore their perspectives. Continual input from a patient and public expert group throughout this project will ensure the patient voice continues to influence the project and how we share our findings with others.  

The abstract is available here and the final report is available here.