According to the World Health Organization (WHO), medications have had an “unprecedented” positive effect on health, affecting mortality and disease burden and leading to an improved quality of life for patients.1 The WHO describes responsible use of medicines as that involving activities, capabilities, and resources of health system stakeholders that align to guarantee patients receive the correct medications at the correct time, use them properly, and benefit from them.1 

Despite this, medications are not always appropriately used and there are missed opportunities when the right medication does not reach the right patient.1 Medications can be overused, underused, and misused, which may lead to adverse events, poor health outcomes (e.g., hospitalization, death), and wasting of resources.1 Potential causes may be that patients do not take their medicines correctly (e.g., nonadherence), or that the capability of a system does not adequately support optimal medicine use.1 Though there are many processes and factors to optimal medication use, several elements identified by the WHO include the availability of effective medicines, a correct and timely diagnosis, and prescribing and dispensing of the appropriate medications in correct quantities, which can be guided by evidence-based treatment guidelines and literature. As previously mentioned, adherence, which is used by the WHO as a term to indicate both compliance and persistence, may also affect responsible use of medicines.1 Previous issues of the Mental Health Clinician have addressed medication adherence and most psychiatric providers have encountered this aspect of suboptimal medicine use.1 Health system capabilities and leadership commitment are also key to optimal medication use.1 Knowing this information, what barriers to safe and appropriate medication use in the psychiatric setting are there? What has been studied and what has been implemented?

Rothschild et al., in a study conducted in a 172-bed academic psychiatric hospital that receives approximately 70,000 medication orders and dispenses approximately 740,000 units of medications during a 6-month period, found that though 50% of all medication orders pertained to psychotropics, these medications were responsible for 92% of adverse drug events.2 Furthermore, atypical antipsychotics were most commonly associated with adverse drug events.2 Procyshyn et al. evaluated medication errors in psychiatry with a focus on patient-, provider-, and system-related issues.3 The authors found patient-related elements that contributed to medication errors included medication nonadherence in addition to failure of the patient to inform multiple providers of all their medications. Provider-related factors included clinical practices related to prescribing, transcribing, dispensing, administering, and monitoring of medications.3 Healthcare system-related factors reported to influence medication errors included failures to maintain continuity of care, inadequate medication reconciliation, insufficient clinical pharmacy services, availability of a nonpunitive medication error reporting system and lack of electronic integration.3 

Regulatory issues pertaining to psychiatric pharmacy span across a multitude of areas including but not limited to safe medication use, facility accreditation, and reimbursement. Specific topics highlighted in this issue include antipsychotic use, medication reconciliation, international accreditation, and opioid use initiatives. All deal with optimizing medication use. In this issue of The Mental Health Clinician, measures used to address the use of antipsychotic polypharmacy, as well as one institution's evaluation of a strategy to reduce costly antipsychotic use are discussed. Dr. Burghart and colleagues details the Joint Commission Hospital-Based Inpatient Psychiatric Services (HBIPS) quality measures meant to reduce inappropriate antipsychotic polypharmacy. Dr. Cupples and colleagues present their findings from an evaluation of an antipsychotic restriction policy and the impact on pre- and post-intervention on outcomes such as number of psychiatric hospitalizations, emergency department visits, and number of prescribed psychotropic medications. Aside from a discussion of HBIPS, a hot topic has been success at achieving the Joint Commission's National Patient Safety Goal involving medication reconciliation. Dr. Newman and colleagues evaluate the implementation and impact on patient care and safety of pharmacist-led medication reconciliation upon discharge. Outside of accreditation, many medication-related issues affect patients and providers on a national level and at many different levels of care. Dr. McKee discusses the opioid medication diversion and misuse, detailing a Chronic Pain Initiative developed in North Carolina aimed at addressing this rising issue.

Some of the topics discussed pertain to measures evaluated for hospital or facility accreditation. The Social Security Act allows providers and suppliers accredited by an approved national accreditation organization to be exempt from surveys by State survey agencies.4 The Joint Commission is commonly referred to and used; however, other approved accrediting organizations include DNV Healthcare, Community Health Accreditation Program, Accreditation Commission for Health Care, Inc., and American Osteopathic Association/Healthcare Facilities Accreditation Program.5 Though many pharmacists in the United States may be aware of accrediting organizations, or are or have been involved in the process of accreditation, this status is also of importance to international facilities. Dr. Wijesinghe practices in a psychiatric facility in Singapore that has been successfully accredited by Joint Commission International multiple times and discusses requirements and practices at the Institute of Mental Health.

Regulatory issues pertaining to psychiatric pharmacy are far-reaching and span across a multitude of processes and individuals. This issue will hopefully provide insight into valuable roles pharmacists have had in not only helping to achieve hospital accreditation but also enhancing patient safety and ensuring optimal medication use.

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Procyshyn
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WG.
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CNS Drugs
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2010
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4.
Accreditation
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Centers for Medicare & Medicaid Services
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5.
CMS-Approved Accreditation Organization Contact Information
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