Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

Medication reconciliation can help identify medication discrepancies during transitions of care. This study examined the impact of a complete medication history database to support pharmacist-led medication reconciliation and identification of medication discrepancies during the admission process for patients at one psychiatric hospital. A retrospective analysis identified 82 medication errors; 90% of these errors – primarily dosage discrepancies and omissions – could have led to patient harm if not corrected through pharmacist intervention.

Patient safety research on inpatient psychiatric care is expanding, but less is known about outpatient mental health patient safety. This review of safety in community-based mental health services revealed several challenges, including defining preventable safety events. Additionally, safety research has focused on harm caused by the patient instead of harm caused by mental health services, such as delays in access or diagnosis.

Daily huddles can improve team communication and awareness of safety incidents. This single-site study found that implementation of daily interdisciplinary huddles increased reporting of near-miss events and improved team satisfaction and perceived team communication, collaboration, and psychological safety.

Inpatient suicide is sentinel event. This study examined treatment patterns among patients undergoing inpatient or outpatient psychiatric treatment who died by suicide. The research team found that patients who were primarily treated with medications were less likely to be sufficiently monitored, whereas patients who received both psychotherapy and medication were more likely to receive inadequate treatment.

Preventing suicide among patients with a mental health diagnosis is a National Patient Safety goal. This study evaluated the impact of the WHO Brief Intervention and Contact (BIC) Program on suicide after psychiatric discharge at six Department of Veterans Affairs (VA) medical centers. After implementation, nearly 82% of patients exhibited positive treatment engagement. Participating healthcare staff reported that the program was easy to use and implement but noted that insufficient staffing and patient loss-to-follow-up can impede program success. A previous WebM&M case and commentary discusses suicide after discharge.

Patient safety event taxonomies provide a standardized framework for data classification and analysis. This taxonomy for inpatient psychiatric care was developed from existing literature, national standards, and content experts to align with the common formats used by the institution’s event reporting system. Four domains (provision of care, patient actions, environment/equipment, and safety culture) were identified, along with categories, subcategories, and subcategory details.

Unplanned discharges (also referred to as leaving against medical advice) can lead to adverse patient outcomes. This study compared unplanned discharges across Veterans Health Affairs (VHA) acute inpatient and residential mental health treatment settings over a ten-year period and found that unplanned discharges are significantly higher in mental health settings. The authors recommend that unplanned discharges be measured to assess patient safety in mental health.

Workplace violence in healthcare settings can jeopardize the safety of both patients and healthcare workers. This study found that over half of healthcare workers at one large academic medical center in the United States reported witnessing or experiencing workplace violence. Witnessing or experiencing workplace violence was most common in psychiatric settings and in the emergency department.  

Cognitive biases can compromise decision making and contribute to poor care. In this study, nurses were provided two patient vignettes as well as associated clinical notes written using either biased or neutral language and asked to make clinical decisions regarding PRN (“as needed”) medication administration for sleep. The study identified a relationship between biased language and clinical decision-making (such as omitting patient education when administering PRN medications).

Patient engagement in safety efforts is encouraged, but patients are less often included as active participants in designing patient safety interventions. This review identified 52 studies that included mental health patients in the design, delivery, implementation, and/or evaluation of patient safety research. The authors argue that increased inclusion of patients in safety research may lead to development of higher quality safety interventions.

Safety gaps in mental health care offers a limited view if focused primarily on patient suicide. This commentary calls for Canadian psychiatric professionals to examine the safety of their patients from a system perspective to develop a research and practice improvement strategy.

Prior research has found that patients who die by suicide often had recent contact with the healthcare setting. Based on a multi-year chart review at one institution, the authors concluded that suicide risk assessment and documentation in the heath record to be insufficient. The authors outline quality improvement recommendations focused on improving documentation, suicide assessment and intervention training, and improving communications with families, caregivers, and other health care providers.

Patient suicide in all settings is considered a never event. Nurses caring for the patient may experience negative psychological symptoms following inpatient suicide. This review identified five themes based on nurses’ psychological experiences: emotional experience, cognitive experience, coping strategies, self-reflection, and impact on self and practice. Hospital administrators should develop education and support programs to help nurses cope in the aftermath of inpatient suicide.  

Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).

Patient safety is an emerging focus within the mental health field. This qualitative study highlights three themes of perceived safe clinical care for patients in a suicidal crisis – being recognized as suicidal, receiving personalized treatment, and adapting care to meet fluctuating behaviors.