Medical errors in psychiatry

Harvard Review of Psychiatry

Volumn 14, Issue 4, 2006, Pages 204-211

  Nath, Sara B ^a   Marcus, Steven C ^b  

^a Bryn Mawr Graduate School of Social Work and Social Research   (United States)

^b UNIVERSITY OF PENNSYLVANIA   (United States)

Author keywords

Error reduction and prevention; Inpatient psychiatry; Medical error; Mental health; Patient safety

Indexed keywords

BIPOLAR DEPRESSION; BIPOLAR DISORDER; COMORBIDITY; CULTURAL FACTOR; DEPRESSION; HEALTH CARE COST; HEALTH CARE SYSTEM; HEALTH PROMOTION; HUMAN; INCIDENCE; MAJOR DEPRESSION; MEDICAL ERROR; MEDICAL RESEARCH; MENTAL DISEASE; MENTAL HEALTH SERVICE; PATIENT CARE; PATIENT SAFETY; PRIORITY JOURNAL; REVIEW; SUICIDE;

COST CONTROL; HEALTH SERVICES RESEARCH; HUMANS; MEDICAL ERRORS; MENTAL HEALTH SERVICES; PSYCHIATRY; RISK FACTORS; UNITED STATES;

EID: 33747484195     PISSN: 10673229     EISSN: 14657309     Source Type: Journal    
DOI: 10.1080/10673220600889272     Document Type: Review

References (65)

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press, 1999.
2. Bogner MS. Introduction. In: Bogner MS, ed. Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum, 1994.
3. Shore MF. Examining the evidence: contributing factors. Psychiatr Serv 2003;54:1599-603.
4. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71.
5. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. N Engl J Med 1991;324:377-84.
6. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med 2003;348:1556-64.
7. Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz H. Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry 2001;58:565-72.
8. Druss BG, Rosenheck RA, Desai MM, Perlin JB. Quality of preventive medical care for patients with mental disorders. Med Care 2002;40:129-36.
9. Reason JT. Human error. Cambridge: Cambridge University Press, 1990.
10. Brennan TA, Leape LL, Laird N, et al. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med 1991;324:370-6.
11. Leape LL. Error in medicine. JAMA 1994;272:1851-7.
12. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA 2005;293:2384-90.
13. Spencer FC. Human error in hospitals and industrial accidents: current concepts. J Am Coll Surg 2000;191:410-8.
14. Helmreich R. On error management: lessons from aviation. BMJ 2000;320:781-5.
15. Chassin MR. Is health care ready for six sigma quality? Milbank Q 1998;76:565-91.
16. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43.
17. Chassin MR, Galvin RW. The urgent need to improve health care quality. JAMA 1998;280:1000-5.
18. Priest SL, Borella AB. A crash course in systems analysis. J Healthc Inf Manage 1998;12:17-23.
19. Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Arch Intern Med 2000;160:2717-28.
20. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34.
21. Campbell DA, Cornett PL. How stress and burnout produce medical mistakes. In: Rosenthal MM, Sutcliffe KM, eds. Medical error: What do we know? What do we do? San Francisco: Jossey-Bass, 2002.
22. Black DW. Iowa record-linkage study: death rates in psychiatric patients. J Affect Disord 1998;50:277-82.
23. Penninx BW, Geerlings SW, Deeg DJ, van Eijk JT, van Tilburg W, Beekman AT. Minor and major depression and the risk of death in older persons. Arch Gen Psychiatry 1999;56:889-95.
24. Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival. JAMA 1993;270:1819-25.
25. Felker B, Yazel JJ, Short D. Mortality and medical comorbidity among psychiatric patients: a review. Psychiatr Serv 1996;47:1356-63.
26. Sternberg DE. Testing for physical illness in psychiatric patients. J Clin Psychiatry 1986;47:3-9.
27. D'Mello DA, Boltz MK, Msibi B. Relationship between concurrent substance abuse in psychiatric patients and neuroleptic dosage. Am J Drug Abuse 1995;21:257-65.
28. Joint Commission on Accreditation of Healthcare Organizations. Preventing adverse events in behavioral health care. Oakbrook Terrace, IL: JCAHO, 1999.
29. Young AS, Sullivan G, Duan N. Patient, provider, and treatment factors associated with poor-quality care for schizophrenia. Ment Health Serv Res 1999;1:201-11.
30. Krakowski MI, Kuntz M, Czobor P, Volavka J. Long-term high-dose neuroleptic treatment: who gets it and why? Hosp Community Psychiatry 1993;44:640-4.
31. Agius RM. Survey of perceived stress and work demands of consultant doctors. Occup Environ Med 1996;53:217-24.
32. Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997;277:312-7.
33. Wennberg JE. The paradox of appropriate care. JAMA 1987;258:2568.
34. Cabana MD, Rand CS, Power NR. Why don't physicians follow clinical practice guidelines? JAMA 1999;282:1453-65.
35. Lehman SF, Steinwachs DM. Patterns of usual care for schizophrenia: initial results from the schizophrenia patient outcomes research team (PORT) client survey. Schizophr Bull 1998;24:11-24.
36. Segal SP, Boal JR, Watson MA. Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services. Psychiatr Serv 1996;47:282-6.
37. Barrio C. The cultural relevance of community support programs. Psychiatr Serv 2000;51:879-84.
38. Aiken L, Clarke S, Sloane D, Sochalski J, Silber J. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288:1987-93.
39. Hay Group. Employer mental health coverage features and compliance with the mental health parity act: Hay report for NIMH. Rockville, MD: National Institute of Mental Health, 1999.
40. Hayes RM, Reiss T. Patient safety forum: Medicare overhaul of 2003. Psychiatr Serv 2004;55:260-1.
41. Leape LL. The preventability of medical injury. In: Bogner MS, ed. Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum, 1994.
42. Conway JB. Patient safety forum: leadership for organizational change. Psychiatr Serv 2004;55:259-60.
43. Grasso BC, Bates DW. Medication errors in psychiatry: are patient being harmed? Psychiatr Serv 2003;54:599.
44. Grasso BC, Genest R, Jordan CW, Bates DW. Use of chart and record reviews to detect medication errors in a state psychiatric hospital. Psychiatr Serv 2003;54:677-81.
45. Haw C, Stubbs J. Prescribing errors at a psychiatric hospital. Pharm Pract 2003;13:64-6.
46. Bates DW. Examining the evidence: evidence of a problem. Psychiatr Serv 2003;54:1599-600.
47. Busch KA, Fawcett J, Jacobs DG. Clinical correlates of inpatient suicide. J Clin Psychiatry 2003;64:14-9.
48. Crenshaw WB, Francis PS. A national survey on seclusion and restraint in state psychiatric hospitals. Psychiatr Serv 1995;46:1026-31.
49. Way BB, Banks SM. Patient characteristics and facility effects. Hosp Community Psychiatry 1990;41:75-81.
50. Weiss E, Altimari D, Blint D, Megan K. Deadly restraint: a Hartford Courant investigative report. Hartford Courant 1998 Oct 11-15.
51. Daumit GL, Pronovost PJ, Anthony CB, Guallar E, Steinwachs DM, Ford DE. Adverse events during medical and surgical hospitalizations for persons with schizophrenia. Arch Gen Psychiatry 2006;63:267-72.
52. Marcus SC, Bressi SK. The impact of psychiatric comorbidity on hospital medical error. Poster presented at National Institute of Mental Health conference Complexities of Co-occurring Conditions, Washington, DC, June 2004.
53. Moray N. Error reduction as a systems problem. In: Bogner MS, ed. Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum, 1994.
54. Grasso BC, Genest R. Use of a personal digital assistant in reducing medication error rates. Psychiatr Serv 2001;52:883-6.
55. Grasso BC, Genest R, Yung K, Arnold C. Reducing errors in discharge medication lists by using personal digital assistants. Psychiatr Serv 2002;53:1325-6.
56. Sharma V, Persad E, Kueneman K. A closer look at inpatient suicide. J Affect Disord 1998;47:123-9.
57. Fawcett J, Scheftner W, Clark D, Hedeker D, Gibbons R, Coryell W. Clinical predictors of suicide in patients with major affective disorders: a controlled prospective study. Am J Psychiatry 1987;144:35-40.
58. Ferraco K, Spath PL. Measuring performance of high-risk processes. In: Spath PL, ed. Error reduction in health care. San Francisco: Jossey-Bass, 2000.
59. Classen DC, Pestotnik SL, Evans S. Computerized surveillance of adverse drug events in hospital patients. JAMA 1991;266:2847-51.
60. Bates DW, Boyle DI, Vliet MV. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995;10:199-205.
61. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:1933-40.
62. Augustine CH, Weick KE, Bagian JP, Lee CZ. Predispositions toward a culture of safety in a large multi-facility health system. In: Enhancing patient safety and reducing errors in health care. Chicago, IL: National Patient Safety Foundation, 1999:138-41.
63. Berwick DM, Leape LL. Reducing errors in medicine. BMJ 1999;319:136-7.
64. Reason JT. Human error: models and management. JAMA 2000;320:768-70.
65. Orkin PK. Patient monitoring during anesthesia as an exercise in technology assessment. In: Saidman LJ, Smith NT, eds. Monitoring in anesthesia. London: Butterworth, 1993.