of medication errors by parents and guardians. A preliminary report also indicates high rates of prescribing errors in outpatient pediatric clinics (McPhillips et al., 2005b).

Psychiatric Care

The committee found only two studies of medication errors in psychiatry (Senst et al., 2001; Grasso et al., 2003). The committee found no studies of psychiatric care that used an independent audit to identify medication errors and then examine a potential causal link between errors and clinical harm. The committee believes medication errors in inpatient and outpatient psychiatry require more study.

Psychiatrist professional organizations have only recently identified medication errors as a patient safety and quality concern. The American Psychiatric Association (APA) first convened its Task Force on Patient Safety in 2002 (Herzog et al., 2003). ADEs were identified as one of four priority areas. The recommendations of the task force were approved by the board of trustees in November 2002 and by the assembly executive committee in January 2003, leading to the inception of the APA Committee on Patient Safety (Herzog et al., 2003).

The committee believes psychiatrists and other mental health professionals should join with their medical and surgical colleagues to speak a common language regarding the detection, reporting, and management of medication errors and ADEs. Broader incorporation of such terminology might also enable a more objective comparison of quality among psychiatric hospitals.

OTC Medications

Apart from the three highly specialized studies on the administration of antipyretics mentioned in the above discussion of pediatric care, the committee found no studies on incidence rates of medication errors arising from use of OTC drugs. Yet there is a growing literature on OTC drug–disease issues and OTC drug–drug interactions (see Box 3-2 in Chapter 3).

Further, a growing number of OTC drugs are being approved, including some that formerly had prescription status. From 1995 to 2004, there were 84 new approvals or prescription-to-OTC switches, an average of 8.4 per year (CDER, 2005). Looking to the future, it is likely that completely new categories of OTC drugs will become available in the United States. In 2004, the United Kingdom approved the first low-dose statin as an OTC drug, provided that a pharmacist reviews the purchase (Bellingham, 2004)—this even though statins do have drug–drug interactions, and it is difficult for patients to monitor either their effectiveness or



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