Psychiatric Quarterly

, Volume 81, Issue 3, pp 197–205

Toward Understanding Errors in Inpatient Psychiatry: A Qualitative Inquiry

  • Sara Wiesel Cullen
  • Sara Bressi Nath
  • Steven C. Marcus

DOI: 10.1007/s11126-010-9129-z

Cite this article as:
Cullen, S.W., Nath, S.B. & Marcus, S.C. Psychiatr Q (2010) 81: 197. doi:10.1007/s11126-010-9129-z


While prior research has identified the impact, nature, and causes of medical error in general medical settings, little is known about errors in inpatient psychiatry. Understanding the broad range of errors that occur in inpatient psychiatry is a critical step toward improving systems of care for a vulnerable patient population. An explorative qualitative analysis of key informant interviews identified a preliminary typology of errors and the contextual factors that precipitate them in inpatient psychiatry. The types of errors and their contextual factors fall broadly within the rubric of categories identified in medicine and surgery. However, many of the specific errors and contextual factors manifest themselves differently and are shaped by the uniqueness of the inpatient psychiatric setting and patient population. Interventions geared toward improving systems of care for psychiatric patients should draw on best practices for safety in medicine and surgery, but also be complemented with new strategies specifically tailored to the inpatient psychiatric setting.


Medical errorInpatient psychiatryPatient safetyError prevention

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Sara Wiesel Cullen
    • 1
  • Sara Bressi Nath
    • 2
  • Steven C. Marcus
    • 1
    • 3
    • 4
  1. 1.School of Social Policy & PracticeUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Bryn Mawr College, Graduate School of Social Work and Social ResearchBryn MawrUSA
  3. 3.Center for Health Equity Research and PromotionPhiladelphia VA Medical CenterPhiladelphiaUSA
  4. 4.Leonard Davis Institute of Health EconomicsPhiladelphiaUSA