Psychiatry - November 2008 - (Page 18)

[adverse events] patient’s mental state, competence, or ability to report accurately? These problems are particular to vulnerable psychiatric patients and could affect their medical care as well. Mortality is not a common occurrence in psychiatry. We could use prior admission, rehospitalization within a month of discharge, unexpected prolongation of hospital stay, adverse drug reactions, medical complications resulting from comorbid conditions, serious cognitive dysfunction as an unexpected outcome of treatment, antipsychotics, plasma concentrations of secondgeneration antipsychotics, and clinical responses.6 Glassman et al7 have described the mechanisms that lead to Torsades de Pointes and sudden death with antipsychotic drugs. Prolongation of the QTc interval and drug-drug interactions that may pose a risk have been described in the literature,7 as have concerns about weight gain, hypoglycemia, diabetes, increases in lipid levels, and cardiovascular events from the use of atypical antipsychotics.8 WE MAY HAVE TO USE SEVERAL LAYERS of screening to determine the impact of an adverse event We need to show that the measure/s used are specific to the event. noncognitive complications of electroconvulsive therapy (ECT), suicide, or other serious self injury with complications as indicators of quality. We could also, for example, include unexpected transfer to a medical service, cardiac complications, and suicide after an improper discharge from the emergency department to assess quality of care. Therapeutic drug monitoring has stimulated clinical pharmacological research including investigations on inherited differences in drug metabolism that are closely linked to drug monitoring in psychiatry. Pharmacokinetic drug interactions play a role in adverse events. Complex tasks involving the prescriber, the lab specialist, and the clinical pharmacologist as well as the patient may result in errors that can be detected by the appropriate use of therapeutic drug monitoring.5 Other adverse events that are commonly discussed for their roles in clinical psychiatry are the pharmacokinetics of atypical 18 Psychiatry 2008 [ N O V E M B E R ] What are some efficient ways for hospitals to target specific psychiatric events with a high percentage of yield either by one or a combination of strategies? The likelihood that an electronic-based system, used by hospitals, will yield more numbers of such events is certain; however, the specificity of such a yield remains to be demonstrated. Also, self reports are highly variable. We need to be able to show that generic screens, such as chart review, do not yield a high rate of false-positive results. What should be the qualifications of the screener to demonstrate reliability? Do all adverse events have a clear, linear relationship with the quality of care? Screens can be combined to reduce false positives. Which of these would be the best way to demonstrate how to improve psychiatric care quality? Also, how do we know if any specified measure is both sensitive and specific for detecting adverse events? Bates9 in 1995 noted that using univariate or multivariate comparisons by logistic regression in which the dependent variable was the presence of an adverse event was important in assessing the validity of the screens that were used. We could, in psychiatry, use both sensitivity and specificity and positive predictive values by the use of reliable screens; we could also determine on what to focus, among our admissions, as adverse events that would be critical to the quality of care. We may have to use several layers of screening to determine the impact of an adverse event. For example, one method might be to use a database of self-reported events followed by a chart audit by two independent, qualified reviewers to calculate interrater reliability, followed by an examination of trends that pertain to a unit of service or individual, and finally, use statistics to measure not mere percentages but reliability as well as validity. We need to show that the measure/s used are specific to the event. Generalizabilty from the examination of events from one urban hospital to other community hospitals or smaller hospitals that are staffed differently or serve less critically ill patients is difficult. Applying lessons learned from one institution may only be partially applicable to others. So we may have to categorize hospitals by tiers of complexity, establish standards or benchmarks, and work with each other to coordinate goals. What about the costs involved in using these strategies? Bates9 estimated these costs. They are not applicable to psychiatry. Such costs are not included in the reimbursement for care provided nor is the time built into job descriptions of various disciplines. Such an effort would take 18

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Psychiatry - November 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Measuring Adverse Events in Psychiatry Nonsuicidal Self Injury in Adolescents Relative Tolerability of Alzheimer's Disease Treatments Biracial Identity Development and Recommendations in Therapy Depression and Cardiovascular Disease: Just an Urban Legend? Three Risk Management Basics Journal Watch Classified Advertising Information for Authors

Psychiatry - November 2008

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