Understanding the medication safety issues affecting patients with mental illness in primary care

Abstract

Background: Mental illnesses are associated with increased morbidity and mortality. Psychotropic medication and psychological therapies have an important role in symptom control and are the mainstay of treatment interventions. A significant number of medication errors occur in primary care settings and, as the majority of patients with mental illness are solely treated in primary care, this may place them at increased risk of preventable medication safety incidents. Understanding the epidemiology and aetiology of medication safety issues is fundamental to the development of theory-driven improvement interventions. Research regarding medication safety in psychiatric inpatient hospitals has gathered pace over recent years and is now moving towards improvement interventions. Despite these advancements, there is a fragmented clinical picture of medication safety issues affecting this patient group in primary care settings, which impedes the development of targeted remedial interventions. Aim: The aim of this PhD was to understand the medication safety issues affecting patients with mental illness in primary care, with a particular focus on their aetiology in order to create an action agenda for clinical practice and future research into priority remedial interventions that are most feasible to change. Methods: The first step involved a scoping review to collate the global evidence base regarding the epidemiology, aetiology and trialled medication safety improvement interventions for patients with mental illness in primary care settings. This was followed by a qualitative interview study with healthcare professionals to understand the causes of preventable medication incidents affecting patients with mental illness in primary care. Interviews followed a critical incident technique and were analysed using the framework method guided by the London Protocol. A focus group study gathering the perspectives of patients with mental illness and their carers regarding medication safety in primary care was then conducted to create a holistic picture of this topic. Focus groups were analysed using the framework method guided by the P-MEDS framework. Finally, the entire dataset generated throughout the programme was presented at a stakeholder-led consensus workshop with healthcare professionals, patients with mental illness and their carers. The workshops followed the nominal group technique and participants voted and agreed upon priority areas to target for remedial interventions that they considered most feasible to change. Results: A total of 79 studies were identified in the scoping review with 77 reporting epidemiology, 25 aetiology and 18 evaluated an improvement intervention. Non-adherence and potentially inappropriate prescribing/medication were the most commonly investigated, with most causal and intervention data relating to non-adherence. Following interviews with 26 primary healthcare professionals, six contributory factors to preventable medication safety incidents were identified: the individual (staff); the work environment; the teams/interfaces; the organisation and management; the patient; and the task and technology. Individual (staff) factors were involved in over 80% of errors discussed with a lack of knowledge regarding neuropharmacology/mental illness and diffusion of responsibility being critical elements. Some factors were unique to this patient group which can affect overall clinical management such as social/behavioural factors. Focus groups conducted with 13 patients with mental illness and/or their carers identified seven themes: communication; trust, involvement and respect; continuity and support; access; the healthcare professional; the patient and carer; and the organisation. The combined datasets were then discussed and voted on at stakeholder-led consensus workshops with mutually agreed areas to target for intervention including communication, holistic continuity of care and follow-up, shared decision-making a

Date of Award	1 Aug 2024
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Richard Keers (Supervisor), Penny Lewis (Supervisor) & Denham Phipps (Supervisor)