National safety priorities in mental health: a national plan for reducing harm

Reducing adverse drug events in mental health services

Page last updated: October 2005


The primary focus of this priority area is to reduce adverse drug events in a mental health service delivery context. Medicines are a critical element in the treatment of many mental health disorders. However, it is essential that medicines are administered in accordance with evidence based guidelines and closely monitored. Medication errors can lead to serious consequences for mental health consumers, including death. Health Ministers have agreed that 'Medication error leading to death of a patient reasonably believed to be due to incorrect administration of drugs' is a publicly reportable sentinel event. The consultation indicated that medication prescribing and administering errors were a high safety priority.

Psychotropic medicines have well known side-effects and contraindications, some of which are associated with serious adverse medication reactions if not adequately monitored. There are also a range of other adverse drug events that occur in mental health care, such as medication errors, which can be reduced through enhanced monitoring and management of psychotropic medicines. Consumers can be on psychotropic medications for long periods of time and may also be taking other medications for other conditions (eg concurrent physical illness or concurrent substance use disorders) or may be under the care of multiple health care professionals.

Mental health professionals are well aware of the occurrence of adverse drug reactions, however, adverse drug events in mental health service settings, including medication errors, are not well researched. A systems oriented approach to reducing adverse drug events is needed, along with a non-punitive culture that rewards error reporting and supports its use in continuous quality improvement.

The National Mental Health Plan 2003-2008 identifies the safe and quality use of medicines as a key action towards improving safety. The National Standards for Mental Health Services state that medicines and other medical technologies are provided in a manner that promotes choice, safety and the best possible quality of life for the consumer. Standard 11.4.C specifically states that mental health services must ensure a system exists for monitoring medicines and properly treating any adverse drug events.

There are a range of initiatives in the area of quality use of medicines and medication management that are complementary to the focus of this Plan and that aim to improve the safe and quality use of psychotropic and other medicines.

Table 3: Reducing adverse drug events in mental health services


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  • Reduced adverse drug events (ADEs) in mental health services.
  • Reduced medication errors involving psychotropic medicines within mental health services and other health services.
  • Increased safe and quality use of psychotropic medicines in mental health services and other health services.

Priority settings

  • Mental health services.
  • Hospital pharmacy services.
  • Other settings, such as primary care settings and mental health consumer home/ community settings (see linked strategies below).

Known problem areas

  • Known side-effects of common psychotropic medicines (such as the anti-psychotic clozapine and movement disorders).
  • Contraindications.
  • Problems related to concurrent medicines (polypharmacy) and comorbidities, for example with depression and diabetes.
  • Problems related to concurrent drug and alcohol use and medicine use.
  • Problems with identifying and recording all medicines that may have contributed to an adverse drug event, including prescribed medicines, illicit drugs, over-the-counter drugs and complementary medicines.
  • Non-oral sedation, particularly when used in emergency psychiatric care.
  • Medication error (dosage, dispensing, prescription, wrong person).
  • Problems related to changing medicines, such as switching between antidepressants particularly those with Selective Serotonen Reuptake Inhibitors (SSRI) group.
  • Overdose, both intentional and accidental.
  • Consumer concerns about side-effects of medicines and their impact on quality of life.
  • Lack of clear mechanisms for consumers and carers to: report adverse drug events; to input quality improvement in the use of medicines; and to provide information on their perceptions of care in relation to medicines.
  • Lack of information provided to consumers about their medicines.
  • Lack of information provided to carers about medicines and changes to medicines, affecting their ability to support consumers.
  • Lack of knowledge of the effects of psychotropic medicines, particularly antidepressants and antipsychotics for which there is a high demand for information.
  • Differing effects of prescription medicines on people from differing gender, cultural and linguistic groups, including Aboriginal and Torres Strait Islander peoples, and the need for further work to identify appropriate and safe use of prescription medicines for specific population, such as children and adolescents, where needed.
  • Related adverse events such as injury through falling. People on psychotropic medicines are at increased risk of falls.
  • Weight gain as a side effect of antipsychotic medicines.Top of page


  • Identify good practice in prescribing and monitoring psychotropic medicines and other evidence-based medicines in mental health services, including specific protocols to document variance from recommended prescribing guidelines, lessons and principles with potential application in other settings, consumer and carer input into decision-making and monitoring processes, communication between different treatment services, and the use of new technologies, such as electronic/ computerised prescribing tools.
  • Develop and implement medication monitoring protocols, electronic systems and documentation practices to flag safety and quality issues and improve medication management systems in mental health services. Include decision support algorithms in such electronic systems.
  • Establish information management systems to detect and report adverse drug events in mental health services at a national level. Such systems to be integrated within existing information management systems and processes.
  • Raise awareness of medication errors in mental health care delivery, drawing on lessons from other areas of health care in regards to systems changes and improvements.
  • Identify good practice services/ leaders and facilitate their role in influencing clinical and service management change. Include consumer and carer perspectives in clinical and service management change processes.
  • Implement clinical practice guidelines in public and private specialised mental health services and other related services, such as primary care, hospital pharmacies, and private office-based psychiatric services.
  • Develop information packages on the use of medicines that are designed for use by consumers and carers as part of individual care planning and integrated into discharge planning and practice. Use existing information packages where available and where they match the consumer and carer information needs.
  • Ensure provision of accurate information to consumers, and where appropriate their carers, about the safe and quality use of their medicines. Ensure such information is integrated into the routine care planning and monitoring. This may require education of health professionals about the need to communicate with consumers about matters of concern to them, such as adverse medicine events.
  • Evaluate changes in practice and outcomes.Top of page

Complementary/ linked strategies/ activities

  • The Quality Use of Medicines in Mental Health Subgroup of the Better Outcomes Implementation Advisory Group was established to work collaboratively with the Pharmaceutical Health and Rational Use of Medicines Committee (PHARM) to improve quality use of medicines in primary mental health care through the Better Outcomes in Mental Health Care initiative.
  • Mainstream health policies and strategies such as National Medicines Policy, National Strategy for Quality Use of Medicines and the activities of bodies such as the Adverse Drug Reactions Advisory Committee (ADRAC), PHARM, the Australian Pharmaceutical Advisory Council (APAC), National Prescribing Service, Health Connect, and the Therapeutic Goods Administration.
  • Professional practice standards for the provision of Consumer Medicine Information (CMI) by pharmacists.
  • Australian Council for Safety and Quality in Health Care initiatives, eg such as the national medication alert system, national sentinel event reporting, Medication Breakthrough Collaboratives, Medication Safety Innovation Awards Program, development of a common inpatient medication chart, 10 tips for safer health care.
  • Implementation of RANZCP Clinical Practice Guidelines for: major depression; schizophrenia; anorexia nervosa; bipolar disorder; and panic disorder and agoraphobia.
  • Improved use of existing information products and services, for example CMI, Medimate, Medicines Line, Adverse Medicine Events (AME) Line, Australian Adverse Drug Reactions Bulletin, SANE Australia's information for consumers and carers on antipsychotic and antidepressant medicines.
  • National Institute of Clinical Studies (NICS) projects and initiatives.
  • Existing State and Territory initiatives, such as the Queensland Health Medication Management Service, and information pamphlets.
  • ACHS Clinical Indicators for Mental Health include indicators related to prescribing patterns of psychotropic medicines.