by Justin Pope, JD

Mr. Pope is Associate Director of Risk Management at Professional Risk Management Services (PRMS).

FUNDING: No funding was provided for the preparation of this article.

DISCLOSURES: The author is an employee of PRMS. PRMS manages a professional liability insurance program for psychiatrists.

This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation and other resources offered to health care providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers might provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other healthcare professionals so “clinician” is used to indicate all treatment team members.

Question

Medical errors are now frequently cited as one of the top causes of death in the United States, and I know that they are more common in certain specialties, like surgery. Are medical errors common in psychiatry, and if so, which medical errors should psychiatrists be mindful of?

Medical errors do exist in psychiatry, but they are less common than in other specialties, such as surgery. In psychiatry, clinicians should be particularly aware of errors in diagnosis and treatment.

Background

Medical errors in the United States. In 1999, the Institute of Medicine report, To Err is Human: Building a Safer Health System, was published.1 This report identified medical errors as a leading cause of death and injury in the United States and estimated that between 44,000 and 98,000 Americans die every year due to preventable adverse events. Subsequently, there has been a national emphasis on patient safety. Most of this early work focused on surgical care and medical errors in hospital settings.

In 2016, a study published in the British Medical Journal estimated that more than 250,000 patients die every year in the United States, making medical error the third leading cause of death.2 The study made national headlines, but it was later strongly criticized for incorrectly using data and for its estimates of death from error. While we may not be entirely sure how many patients die from medical errors every year, it is important to recognize that all clinicians can make errors in clinical care. Understanding these errors is vital to improving processes and systems of care.

Terminology. In the absence of a clear consensus on definitions, below is a reasonable risk management approach to Rodziewicz et al’s3 extensive discussion of medical error terminology:

Medical error: A clinical act that deviates from the standard care process that may or may not result in patient harm.

Adverse event: Patient injury as a result of clinical treatment (not an underlying condition) that may or may not involve a medical error.

Near miss: A medical error that could have been an adverse event but did not harm the patient, either because the error was caught or due to sheer luck.

Never event: Medical error that should never have happened (eg, wrong-site surgery).

Active errors vs latent errors: Active errors involve the clinician providing some type of care (eg, a surgeon amputating the wrong leg) while latent errors are intrinsic failures within the patient care process (eg, faulty installation or maintenance of equipment; ineffective organizational structure).

Errors of commission vs errors of omission: Errors of omission occur as a result of actions not taken (eg, not assessing suicide risk prior to discharge), while errors of commission occur as a result of the wrong action taken (eg, prescribing a medication to which the patient has a known allergy).

Lastly, a sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm.4 A relevant example is a patient suicide.

Medical Errors in Psychiatry

There are 2 models of causation of error.5 The first is the individual approach, focusing on the errors of individuals and often attributing error to provider forgetfulness, inattention, or moral failure. The second is the systems approach, focusing on conditions and systems under which individuals work as the source of the error. The aims of both models are to understand origins of error and to prevent and mitigate their effects.

However, patient safety theory now stresses that patient safety is based on systems components, not just one clinician. Hospital systems are complex and technological—and therefore, prone to accidents. Office-based psychiatric settings are also subject to systems errors. Consider the various elements in an office-based system: patient, clinician, office staff, electronic health record, pharmacy, labs, primary care provider, and payers, to name a few.

In their article, “Medical Errors in Psychiatry,” Nath and Marcus6 state the following as factors unique to psychiatry:

  • Patients with serious and persistent mental illness may be uniquely vulnerable to poor healthcare due to symptoms of, and attitudes about, their mental conditions.
  • Cognitive and mood disturbances may preclude accurate reporting of symptoms, delay help-seeking, or complicate differential diagnoses.
  • Fear of violence and other difficulties in communicating with patients may impede providers’ ability to prescribe dosages with guidelines.
  • Providers might make mistakes in drug dosing if stigma or lack of cultural awareness lead to poor communication with patients.
  • Institutional structures, processes, operations, and incentives can actually encourage or cause errors and decrease safety.
  • Mental health systems may be especially and increasingly strained and vulnerable to medical errors.

Inadequate health insurance coverage and a lack of community resources significantly limit the mental health system’s ability to offer patients coordinated care as they move though inpatient, outpatient, and specialty-care settings.

Errors in inpatient psychiatric practice have been studied more than in the outpatient setting, but much of what is found in inpatient literature also applies to outpatient treatment. Nath and Marcus present 2 key categories of errors:6

  • Errors in diagnosis include delays in formulating appropriate diagnoses, failure to use appropriate techniques for making diagnoses, and failure to act on the results of diagnostic tools. For example, when admitting patients, psychiatric units might not use the tests available to assess comorbid medical or substance use disorders.
  • Errors in treatment include errors in administering treatment and medications, avoidable delays in initiating treatment, and inappropriate care. For example, failure to monitor suicidal patients or provide adequate assessment of their suicide risk could place patients in danger.

In our experience as a provider of medical malpractice liability insurance for psychiatrists, suicide and medication cases have always been our top 2 identifiable causes of loss. The most common medical errors alleged in our suicide cases include:

  • Inadequate suicide risk assessments;
  • Inadequate treatment plan development;
  • Inadequate treatment plan implementation;
  • The care provided was not professionally current; and
  • Poor documentation resulting in patient harm—while documentation serves a variety of functions, the primary purpose of documentation is for continuity of care.

The most common medication errors alleged in our psychopharmacology cases include:

  • Absence of an indication for the drug prescribed;
  • Medication is contraindicated;
  • Medication conflicts with known allergies;
  • Inappropriate dosing;
  • The order is transcribed or entered incorrectly for drug, dosage, frequency, or identity of the patient;
  • Administration errors, such as the medication is given to the wrong patient; and
  • Monitoring errors, such as failing to order lithium level tests or ordering tests but not reviewing the results of testing done by the primary care physician.

Conclusion

While perhaps less frequent than in other specialties, medical errors do occur in psychiatry. By recognizing and understanding how and why these errors occur in psychiatric settings, clinicians can work to address safety gaps and implement appropriate policies and procedures. In Part 2 of this article, we will continue our discussion on preventing and managing medical errors.

References

  1. To Err is Human: Building a Safer Health System. Summary. National Academy of Sciences. Nov 1999. Accessed 9 Feb 2026. https://nap.nationalacademies.org/resource/9728/To-Err-is-Human-1999–report-brief.pdf
  2. Ranji S. Measuring and responding to deaths from medical errors. Patient Safety Network. 22 Mar 2016. Accessed 9 Feb 2026. https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
  3. Rodziewicz TL, Houseman B, Vaqar S, Hipskind JE. Medical error reduction and prevention. StatPearls. Treasure Island (FL): StatPearls Publishing. Updated 12 Feb 2024. Accessed 9 Feb 2026. https://www.ncbi.nlm.nih.gov/books/NBK499956/
  4. Sentinel events. Joint Commission. Accessed 9 Feb 2026. https://www.jointcommission.org/en-us/knowledge-library/sentinel-events
  5. Reason J. Human error: models and management. BMJ. 2000;320(7237):768–770.
  6. Nath SB, Marcus SC. Medical errors in psychiatry. Harv Rev Psychiatry. 2006;14(4):204–211.