Preventing Missed Prescriptions on Admission to a Mental Health Ward

Preventing Missed Prescriptions on Admission to a Mental Health Ward

Case Background

A patient suffered from paranoid schizophrenia, alcohol dependency and epilepsy.

Whilst under the care of a mental health team, upon admission to the ward, the patient was not supplied with epilepsy medication, or any anticonvulsant medication whilst admitted, despite the patient suffering from the condition for a prolonged length of time. Prescription assessments were not undertaken on admission which led to the patient missing multiple doses of epilepsy medication whilst on the ward.

Independent Recommendations to Improve Healthcare Standards and Patient Safety

When a patient is admitted on to a mental health ward, their prior medical history should always be reviewed and assessed to make sure that they are receiving the best care and have access to all their prescription needs.

If a patient does not have access to their usual medication, they could suffer the effects of withdrawal or they could experience adverse symptoms such as seizures attributed to epilepsy, or delayed healing, if recovering from surgery.

Whilst mental health is extremely important in maintaining the wellbeing of a patient, their physical needs also need to be monitored and maintained, to keep the patient safe whilst under the care of clinicians.

To prevent adverse side effects due to medication needs not being met whilst the patient is under the care of a mental health team, there are a number of measures to bear in mind to reduce the risk of harm befalling a patient.

Preventing Missed Prescriptions

Checking on Admission

Upon admission, patients should be assessed to determine what medication they take and what for. In instances where the patient may have conditions, such as epilepsy, thyroid conditions or even asthma, their usual medication to deal with these health conditions should be available to maintain physical health, whilst the clinicians can address their mental health.

GP Records

Prescription assessments should be completed before or when the patient is admitted, to prevent delays in getting their medication. This can be done ahead of time, or if needed, on the day. Clinicians should bear in mind that the mental health ward needs to work alongside the patient’s GP to send over all relevant records and prescriptions to maintain the care of the patient. By requesting the patient’s records, the mental health team can review the patient’s diagnoses, conditions and the resulting prescription needs, to keep crossover delays to a minimum.

This can also assist to prevent neutralisation or excessive doses when prescribing new medications related to their mental health whilst on the ward.

Correlation

Clinicians should bear in mind the importance of checking the patient’s records for conditions and previous history on admission, that can aid in preventing missed opportunities for medications to be administered whilst on the ward. Comparing and correlating medical records against the GP records can assist in double checking that the correct prescriptions have been obtained.

Familial Concerns

The importance of listening to the family of the patient, or the patient themselves, should not be overlooked. Often, when patients are admitted for mental health care, their families can provide much needed information on how the patient has been coping and in particular, what they require.

If a patient’s family raises concerns about medication or prescriptions, these should be reviewed to confirm that the patient is receiving the appropriate care. Taking the time to verify medical needs can limit litigation risk in the future and can aid in maintaining patient safety.

Conclusions

When a patient is admitted on to a mental health ward, their physical conditions cannot be overlooked, and a medication assessment should be carried out to confirm what the patient needs to have access to. The ward should work alongside the patient’s GP, to obtain and verify the prescriptions to reduce the risk of the patient missing any doses of medication.

By raising awareness of the above issues, THEMIS and TMLEP aim to assist in developing awareness of carrying out medication assessments upon admission to a mental health ward, to make sure that a patient’s physical health can be monitored and preserved whilst receiving care for their mental health, thereby improving clinical care and reducing litigation risk.

References

  • Co-written by THEMIS Clinical Risk and Patient Safety Publishing Group and Ms Kayley Newman, Analyst at TMLEP. . (2021). Preventing Missed Prescriptions on Admission to a Mental Health Ward. TMLEP Clinical Risk Case Studies. 7 (7), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.