Table_2_unDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in community caRe (DISCOVER): a qualitative study.XLSX

BackgroundIt is estimated that 237 million medication errors occur in England each year with a significant number occurring in the community. Our understanding of the causes of preventable medication errors and adverse drug events (ADE) affecting patients with mental illness is limited in this setting. Better understanding of the factors that contribute to errors can support the development of theory-driven improvement interventions.
MethodsRemote qualitative semi-structured interviews with 26 community-based healthcare professionals in England and Wales were undertaken between June–November 2022. Recruitment was undertaken using purposive sampling via professional networks. Interviews were guided by the critical incident technique and analysed using the framework method. Any data that involved speculation was not included in the analysis. Independent analysis was carried out by the research team to extract themes guided by the London Protocol.
ResultsA total of 43 medication errors and 12 preventable ADEs were discussed, with two ADEs having an unknown error origin. Prescribing errors were discussed most commonly (n = 24), followed by monitoring errors (n = 8). Six contributory factor themes were identified: the individual (staff); the work environment; the teams/interfaces; the organisation and management; the patient; and the task and technology. The individual (staff) factors were involved in just over 80% of all errors discussed. Participants reported a lack of knowledge regarding psychotropic medication and mental illnesses which accompanied diffusion of responsibility. There were difficulties with team communication, particularly across care interfaces, such as ambiguity/brevity of information being communicated and uncertainty concerning roles which created confusion amongst staff. Unique patient social/behavioural contributory factors were identified such as presenting with challenging behaviour and complex lifestyles, which caused difficulties attending appointments as well as affecting overall clinical management.
ConclusionThese findings highlight that the causes of errors are multifactorial with some unique to this patient group. Key areas to target for improvement include the education/training of healthcare professionals regarding neuropharmacology/mental illnesses and enhancing communication across care interfaces. Future research should explore patient perspectives regarding this topic to help develop a holistic picture. These findings can be used to guide future intervention research to ameliorate medication safety challenges for this patient group.

背景：据估算，英格兰每年发生2.37亿起用药错误，其中相当一部分发生在社区医疗场景中。目前，针对社区场景中影响精神疾病患者的可预防用药错误及药物不良事件（ADE）的致病诱因，我们的认知仍较为有限。深入厘清此类错误的促成因素，可为开发基于理论的改进干预措施提供支撑。
研究方法：2022年6月至11月期间，针对英格兰及威尔士的26名社区医疗从业人员开展了远程质性半结构化访谈。招募采用目的性抽样策略，通过专业医疗网络进行。访谈以关键事件法（critical incident technique）为指导框架，采用框架分析法进行数据分析。所有涉及推测性内容的数据均未纳入分析范畴。研究团队独立开展编码分析，并依据伦敦协议（London Protocol）提炼核心研究主题。
研究结果：本次访谈共讨论了43起用药错误与12起可预防的药物不良事件（ADE），其中2起药物不良事件的错误源头尚未明确。其中处方差错的讨论频次最高（n=24），其次为监测差错（n=8）。研究共识别出6类促成错误的核心主题：从业人员个体层面、工作环境层面、团队/跨护理界面协作层面、组织与管理层面、患者层面，以及任务与技术层面。从业人员个体层面的因素在逾80%的讨论案例中均有涉及。参与者反馈，医护人员对精神药物及精神疾病相关知识的匮乏，伴随责任扩散现象。团队沟通存在显著障碍，尤其是在跨护理界面场景中，具体表现为信息传递模糊或过于简略、岗位职责界定不清，导致医护人员产生认知困惑。此外还识别出该患者群体特有的社会/行为促成因素，例如患者存在挑战性行为及复杂生活方式，这不仅导致其难以按时赴约就诊，还会对整体临床管理造成阻碍。
研究结论：本研究结果显示，用药错误的诱因具有多因素性，其中部分诱因仅见于精神疾病患者群体。需重点改进的关键领域包括：针对医护人员开展神经药理学/精神疾病相关的教育培训，以及优化跨护理界面的沟通协作机制。未来研究应探究患者对此议题的视角，以构建全面完整的认知图景。上述研究结果可用于指导后续干预研究，以改善该患者群体面临的用药安全挑战。