Table_1_unDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in community caRe (DISCOVER): a qualitative study.DOCX

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.

【研究背景】据估算，英国每年发生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。目前学界针对社区场景下影响精神疾病患者的可预防用药错误与药物不良事件（Adverse Drug Event, ADE）的致病原因认知仍较为有限。深入明晰此类错误的诱发因素，可为基于理论构建的医疗质量改进干预方案提供支撑。

【研究方法】本研究于2022年6月至11月期间，针对英格兰与威尔士的26名社区医疗从业人员开展远程半结构化质性访谈。研究通过专业网络采用目的抽样法完成招募。访谈以关键事件技术（Critical Incident Technique, CIT）为指引框架，数据分析采用框架分析法（Framework Method）完成。本研究未纳入任何包含主观推测的访谈数据，研究团队独立开展分析，并依据伦敦议定书（London Protocol）提取核心主题。

【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，其中2起药物不良事件的错误诱因未明确。最常被提及的为处方错误（n=24），其次为监测错误（n=8）。本研究共识别出6类诱发因素主题：从业人员个体因素、工作环境因素、团队/跨照护界面因素、组织与管理因素、患者因素，以及任务与技术因素。在所有讨论的错误中，超80%涉及从业人员个体因素。受访对象提及，从业人员对精神科药物与精神疾病相关知识的匮乏，叠加责任扩散效应，加剧了用药风险。团队沟通存在明显障碍，尤其是跨照护界面的沟通：如传递的信息模糊或过于简短，且岗位权责边界不清，导致从业人员产生认知混淆。此外还识别出针对该患者群体特有的社会/行为类诱发因素，例如患者存在挑战性行为与复杂生活模式，这不仅导致患者难以按时就诊，也对整体临床诊疗管理造成干扰。

【研究结论】本研究结果表明，用药错误的诱因具有多因素特征，且部分诱因仅存在于精神疾病患者群体中。亟待改进的核心方向包括：开展针对从业人员的神经药理学与精神疾病相关教育培训，以及强化跨照护界面的沟通协作。未来研究应纳入患者视角，以构建更全面的认知体系。本研究结果可用于指导后续干预类研究，以改善该患者群体的用药安全挑战。