Article Text

Download PDFPDF
Medication errors in mental healthcare: a systematic review
  1. Ian D Maidment1,
  2. Paul Lelliott2,
  3. Carol Paton3
  1. 1Kent & Medway NHS & Social Care Partnership Trust, St Martin’s Hospital, Canterbury, UK
  2. 2Royal College of Psychiatrists’ Research and Training Unit; Oxleas NHS Trust, London, UK
  3. 3Oxleas NHS Trust, Dartford, Kent, UK
  1. Correspondence to:
 Ian D Maidment
 Eastern & Area Coastal Office, St Martin’s Hospital, Littlebourne Road, Canterbury, Kent CT1 1AZ, UK; ian.maidment{at}


Background: It has been estimated that medication error harms 1–2% of patients admitted to general hospitals. There has been no previous systematic review of the incidence, cause or type of medication error in mental healthcare services.

Methods: A systematic literature search for studies that examined the incidence or cause of medication error in one or more stage(s) of the medication-management process in the setting of a community or hospital-based mental healthcare service was undertaken. The results in the context of the design of the study and the denominator used were examined.

Results: All studies examined medication management processes, as opposed to outcomes. The reported rate of error was highest in studies that retrospectively examined drug charts, intermediate in those that relied on reporting by pharmacists to identify error and lowest in those that relied on organisational incident reporting systems. Only a few of the errors identified by the studies caused actual harm, mostly because they were detected and remedial action was taken before the patient received the drug. The focus of the research was on inpatients and prescriptions dispensed by mental health pharmacists.

Conclusion: Research about medication error in mental healthcare is limited. In particular, very little is known about the incidence of error in non-hospital settings or about the harm caused by it. Evidence is available from other sources that a substantial number of adverse drug events are caused by psychotropic drugs. Some of these are preventable and might probably, therefore, be due to medication error. On the basis of this and features of the organisation of mental healthcare that might predispose to medication error, priorities for future research are suggested.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Competing interests: None.