Adverse medication events in a psychiatric practice: a naturalistic study

Aims and method To document the number and type of adverse medication events in a psychiatric sector service. Significant new adverse events were collated by the author and team over 30 months. Intervention to prevent any adverse event was enacted as soon as any were noticed or anticipated. Results Thirty-six significant events occurred including three deaths and nine near misses. Corrective action was taken immediately any adverse event occurred. Inadequate communication between various hospital clinics, general practitioner practices, psychiatric clinics and pharmacies was the biggest avoidable cause of adverse events. Clinical implications Awareness of adverse drug events is essential in psychiatry. Clear, transparent pathways of prescribing are a key requirement to reduce avoidable adverse medication events. Psychopharmacology is a core module for psychiatric training.