The nature of prescribing errors in psychiatric setting: a narrative-behavioural and Delphi study

Abstract Background The nature of prescribing errors (PE) in psychiatric setting is unclear. PE is a healthcare quality marker and a public health concern. Purpose of the study is to examine the nature of PE. Methods A one-year observational study (Jan.2024-2025) is conducted at St. Josef psychiatric hospital AMEOS, Oberhausen, Germany and approved by ethics committee. PE from therapeutic protocols (TP) were identified according to EQUIP method. For each PE, a modified data collection (interview of responsible person - RP) was included according to a previous study by Slight et al., followed by a double-blind review and then a Delphi consensus to identify the nature of the PE. Observers recorded behavioral patterns of the RP (Pope et al., 2000). Results Out of 7020 TP (64% male: 36% female, median age: 52 ± 6.4, median length stay: 6.3 days), 3143 included PE. 91% concerned anti-inflammatory and analgesics, without side effects on psychopathology or health status. 98% of PE were dosage (56%) and writing (42%) related. For the dosage PE, 95% addressed educational issues. RP were residents. For writing PE is observed a heterogeneity. 84% of PE were due to time deficiency, leading to reading difficulties. 13% were writing medication PE, almost repeatedly. 71% of PE concerned as RP the nurses, 24% the residents, 5% the consultants. We extracted keywords from RP according to the frequency mentioned: time pressure, unknown medication, difficult to write-spelling, poor lighting, reading-communication problems. After the Delphi process, the first three keywords were defined as main reasons for PE and the last as minor reasons. Conclusions A great heterogeneity is observed upon the nature of PE in psychiatric setting, with major RP the nurses and residents. Training in medication prescribing and pharmacotherapy is essential. Key messages • Due to the nature of the problem, prescribing errors in psychiatric settings are heterogeneous and challenging to address as an important public health issue. • Educational interventions are needed to prevent prescribing errors.