Aims and methodTo document the number and type of adverse medication events in a
psychiatric sector service. Significant new adverse events were collated
by the author and team over 30 months. Intervention to prevent any
adverse event was enacted as soon as any were noticed or anticipated.ResultsThirty-six significant events occurred including three deaths and nine
near misses. Corrective action was taken immediately any adverse event
occurred. Inadequate communication between various hospital clinics,
general practitioner practices, psychiatric clinics and pharmacies was
the biggest avoidable cause of adverse events.Clinical implicationsAwareness of adverse drug events is essential in psychiatry. Clear,
transparent pathways of prescribing are a key requirement to reduce
avoidable adverse medication events. Psychopharmacology is a core module
for psychiatric training.