A rating scale for drug-induced akathisia has been derived that incorporates diagnostic criteria for pseudoakathisia, and mild, moderate, and severe akathisia. It comprises items for rating the observable, restless movements which characterise the condition, the subjective awareness of restlessness, and any distress associated with the akathisia. In addition, there is an item for rating global severity. A standard examination procedure is recommended. The inter-rater reliability for the scale items (Cohen's kappa) ranged from 0.738 to 0.955. Akathisia was found in eight of 42 schizophrenic in-patients, and nine had pseudoakathisia, where the typical sense of inner restlessness was not reported.

A rating scale for drug-induced akathisia

The role of serotonin in antipsychotic drug action

Background: Interruptions have been implicated as a cause of clinical errors, yet, to our knowledge, no empirical studies of this relationship exist. We tested the hypothesis that interruptions during medication administration increase errors. Methods: We performed an observational study of nurses preparing and administering medications in 6 wards at 2 major teaching hospitals in Sydney, Australia. Procedural failures and interruptions were recorded during direct observation. Clinical errors were identified by comparing observational data with patients’ medication charts. A volunteer sample of 98 nurses (representing a participation rate of 82%) were observed preparing and administering 4271 medications to 720 patients over 505 hours from September 2006 through March 2008. Associations between procedural failures (10 indicators; eg, aseptic technique) and clinical errors (12 indicators; eg, wrong dose) and interruptions, and between interruptions and potential severity of failures and errors, were the main outcome measures. Results: Each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors. The association between interruptions and clinical errors was independent of hospital and nurse characteristics. Interruptions occurred in 53.1% of administrations (95% confidence interval [CI], 51.6%-54.6%). Of total drug administrations, 74.4% (n=3177) had at least 1 procedural failure (95% CI, 73.1%-75.7%). Administrations with no interruptions (n=2005) had a procedural failure rate of 69.6% (n =1 395; 95% CI, 67.6%-71.6%), which increased to 84.6% (n=148; 95% CI, 79.2%-89.9%) with 3 interruptions. Overall, 25.0% (n=1067; 95% CI, 23.7%26.3%) of administrations had at least 1 clinical error. Those with no interruptions had a rate of 25.3% (n=507; 95% CI, 23.4%-27.2%), whereas those with 3 interruptions had a rate of 38.9% (n=68; 95% CI, 31.6%-46.1%). Nurse experience provided no protection against making a clinical error and was associated with higher procedural failure rates. Error severity increased with interruption frequency. Without interruption, the estimated risk of a major error was 2.3%; with 4 interruptions this risk doubled to 4.7% (95% CI, 2.9%-7.4%; P.001). Conclusion: Among nurses at 2 hospitals, the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors.

/pdf/association-of-interruptions-with-an-increased-risk-and-59pw2yti4u.pdf

Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors

The British National Formulary.

Aims To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010.

Methods  A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword ‘benzodiazepine(s)’, alone and in conjunction with various terms such as ‘dependence’, ‘abuse’, etc. Further hand-searches were made based on the reference lists of key papers. As 60 000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse.

Results  Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose ‘iatrogenic’ dependence and high-dose abuse/misuse is emphasized.

Conclusions  The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk–benefit ratio of the benzodiazepines remains positive in most patients in the short term (2–4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal.

Benzodiazepines revisited—will we ever learn?

Background. Relatively little is known about medication administration errors in mental health settings. Objective. To investigate the frequency and nature of medication administration errors in old-age psychiatry. To assess the acceptability of the observational technique to nurse participants. Method. Cross-sectional study technique using (i) direct observation, (ii) medication chart review and (iii) incident reports. Setting. Two elderly long-stay wards in an independent UK psychiatric hospital. Participants. Nine nurses administering medication at routine medication rounds. Main outcome measures. Frequency, type and severity of directly observed medication administration errors compared with errors detected by retrospective chart review and incident reports. Results. Using direct observation 369 errors in 1423 opportunities for errors (25.9%) were detected vs. chart review detected 148 errors and incident reports none. Most errors were of doubtful or minor severity. The pharmacist intervened on four occasions to prevent an error causing patient harm. The commonest errors observed were unauthorized tablet crushing or capsule opening (111/369, 30.1%), omission without a valid reason (100/369, 27.1%) and failure to record administration (87/369, 23.6%). Among the nurses observed, the error rate varied widely from no errors to one error in every two doses administered. Of the seven nurses who completed the post-observation questionnaire, all said they would be willing to be observed again. Conclusion. Medication administration errors are common and mostly minor. Direct observation is a useful, sensitive method for detecting medication administration errors in psychiatry and detects many more errors than chart review or incident reports. The technique appeared to be acceptable to most of the nursing staff that were observed.

An observational study of medication administration errors in old-age psychiatric inpatients

Background: Many older patients have difficulty in swallowing their tablets and capsules. Dose form modification, by crushing tablets or opening capsules, is often used by nurses to administer such medication.Methods: Electronic searches of five literature databases on tablet crushing and capsule opening were carried out. A review of medication incident reports involving tablet crushing from the U.K. National Reporting and Learning System (NRLS) was also undertaken. An observational study of medication administration on two long-stay wards for older mentally ill inpatients was carried out in a large psychiatric hospital.Results: Only 17 incidents involving tablet crushing were reported to NRLS in 13 months. In the observational study, the administration of 1257 oral doses of medication at 36 medication rounds was observed. Tablets were crushed or capsules opened for 25.5% (266/1045) of solid oral doses. For 44.0% (117/266) of these doses the tablet crushing had not been authorized by the prescriber. For 4.5% (12/266) of doses crushing was specifically contra-indicated by the manufacturer. In 57.5% (153/266) of doses, tablet crushing was avoidable by the correct use of more suitable preparations. Crushing caused contamination, spillage and hygiene problems.Conclusions: Although tablet crushing and capsule opening are common practices, they are rarely reported as causing patient harm. Tablet crushing can often be avoided by the use of more suitable preparations. Crushing tablets and opening capsules are contra-indicated for some preparations. Older patients' medication may benefit from review by a pharmacist in order to optimize safe medication administration. Where tablet crushing is unavoidable, attention to cleanliness, contamination and spillage are necessary.

Dose form modification - a common but potentially hazardous practice. A literature review and study of medication administration to older psychiatric inpatients.

A retrospective analysis of reports of medication administration errors over a period of three and a half years was carried out in a UK psychiatric hospital. A total of 112 errors and "near misses" were studied. The reporting rate increased over time. Psychotropic, intramuscular, and as-needed medications were overrepresented in the error reports. Fifteen percent of the errors had the potential to cause moderate or severe harm to patients. The two most common factors cited by nurses as contributing to error causation were a busy, noisy environment and personal factors, such as feeling tired or unsupported. Physicians were cited as having contributed to some errors.

https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.56.12.1610

A Review of Medication Administration Errors Reported in a Large Psychiatric Hospital in the United Kingdom

The aim of this study was to report on forensic rehabilitation inpatients' experiences and preferences for physical restraint, seclusion and emergency intra-muscular medication using mixed qualitative and quantitative methods. Of 252 inpatients, 79 met the study inclusion criteria and 57 (72%) agreed to take part. Just over half thought they should have been subjected to coercive treatment. Although coercive treatments were generally perceived as negative experiences, 16% of participants reported the last episode of seclusion or restraint had been a positive experience for them. The figure for emergency intra-muscular medication was 36%. Eleven percent of participants said they had made an advance statement but none could be found in their records. Most participants preferred intra-muscular medication to seclusion. Participants made suggestions as to how to improve their experiences of coercive treatments. Patients' views on coercive treatments should be incorporated into their care plans and they should ...

Coercive treatments in forensic psychiatry: a study of patients' experiences and preferences

Medication errors are an important cause of patient morbidity and mortality, of which there have been few reports in psychiatry, especially in the UK. Our aim was to examine the nature, frequency and potential severity of prescribing errors in UK mental health units in a prospective, 1 week survey of errors detected by pharmacy staff in nine NHS trusts. Pharmacists checked 22036 prescription items. In total, 523 errors meeting the study definition were detected (2.4% of prescription items checked). Prescription writing errors (77.4%) were most common, while decision-making errors accounted for 22.6% of errors. In 280 (53.5%) cases the prescribed drug had been administered before the error was detected. Most errors were of doubtful or minor importance but 22 (4.3%) were deemed likely to result in serious adverse effects or death. The error detection rate varied fourfold between trusts. Prescribing errors are fairly common in psychiatry. A small proportion of errors have the potential for serious harm. Pharmacy staff have an important role to play in their management.

Jean Stubbs

Papers

An observational study of medication administration errors in old-age psychiatric inpatients

Dose form modification - a common but potentially hazardous practice. A literature review and study of medication administration to older psychiatric inpatients.

A Review of Medication Administration Errors Reported in a Large Psychiatric Hospital in the United Kingdom

Coercive treatments in forensic psychiatry: a study of patients' experiences and preferences

Prescription errors in psychiatry - a multi-centre study.