The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 56 Results

Walking Out of a Hospital After Attempted Suicide.

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WebM&M Case September 27, 2023

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring.

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri.

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Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146.

This report analyzed a patient suicide at an emergency department and determined factors in the delay of care that contributed to patient harm. This report shares recommendations to address leadership failures and other deficiencies including poor screening and patient monitoring. Post-event gaps identified include poor root cause analysis, disclosure, and reporting activities.

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

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Washington DC: Department of Veterans Affairs, Office of Inspector General; May 10, 2023. Report no. 22-01116-110.

Death of a patient by suicide is a sentinel event. This report examined one incident and identified care deficiencies associated with lack of mental health referrals and pain management follow-up. In addition, post-event process gaps occurred, impacting learning and resolution such as a delay in the inquiry launch, peer review, and clinical review of the incident. Claims that the facility purposely sought to hide information that the suicide happened were unsubstantiated.

Systems approach to suicide prevention: strengthening culture, practice, and education.

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Pisani AR, Boudreaux ED. Focus (Am Psychiatr Publ). 2023;21:152-159.

Identifying patients with suicidal ideation can be a challenging clinical problem in the emergency department. These authors use a systems-based approach to identify missed opportunities to prevent suicide and present a systems approach to suicide prevention including three core domains – a culture of safety and prevention, applying best practices and policies for prevention in systems, and workforce education and development.

The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.

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WebM&M Case June 14, 2023

A 25-year-old female was sent by ambulance to the emergency department (ED) by a mental health clinic for suicidal ideation. Upon arrival to the ED, she was evaluated by the triage nurse and determined to be awake, alert, calm, and cooperative and she denied current suicidal thoughts. The ED was extremely busy, and the patient was placed on a gurney with a Posey restraint in the hallway next to the triage station awaiting psychiatric social work assessment. Approximately 40 minutes later, the triage nurse noticed that the patient was missing from the gurney.

Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial.

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Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;80:665-674.

Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.

Care Delivery within Community Mental Health Teams.

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Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.

Patient suicide is a sentinel event. This report examines a suicide incident that identified problems with risk assessment and identification, family engagement, and medication management in the context of mental health provision when supporting patients in psychological distress.

Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.

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WebM&M Case March 29, 2023

An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting psychiatrist evaluated the patient but recommended sending her home on a benzodiazepine alone, under observation by her mother.

Few hospitals are willing to bear the cost of providing psychiatric care for kids.

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Schorsch K, Karp S. WBEZ Chicago. March 9, 2023.

Pediatric mental health is a patient safety concern. This news story outlines the challenges to available services to address this need, tactics to keep young patients from harming themselves or others, and system-level approaches to improvement.

Crisis in the Lakeshore Hospital ER.

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Derfel A. Montreal Gazette. February 24- March 1, 2023

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.

Patients who die by suicide: a study of treatment patterns and patient safety incidents in Norway.

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Krvavac S, Jansson B, Bukholm IRK, et al. Int J Environ Res Public Health. 2022;19:10686.

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.

Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative.

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Riblet NB, Varela M, Ashby W, et al. Jt Comm J Qual Patient Saf. 2022;48:503-512.

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.

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.

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Berg SH, Rørtveit K, Walby FA, et al. BMC Health Serv Res. 2022;22:967.

Inpatient suicides are considered a never event. Based on patient and provider interviews and a literature review, this paper describes the development of resilience in inpatient psychiatric settings. The main theme is establishment of relationship of trust between patients and providers.

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

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Washington, DC: VA Office of the Inspector General; February 17, 2022. Report No. 21-01506-76.

Patient suicide is a reoccurring sentinel event that is a challenge for the veteran’s health care community. This report shares the results of 36 unplanned inspections at United States Veterans Affairs facilities. While the inspections found general guidance compliance to be in place, weaknesses in required patient follow-up, staff training and outreach activities were flagged as areas in need of targeted improvement to enhance patient safety.

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017.

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Zheng MY, Lui H, Patino G, et al. J Patient Saf. 2022;18:e401-e406.

California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs.

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Shah F, Falconer EA, Cimiotti JP. Qual Manag Health Care. 2022;31:231-241.

Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.

Zero Suicide Initiative.

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Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893.

Patient suicide attempts are considered never events. This funding announcement calls for program applications to motivate suicide prevention strategy implementation in the indigenous peoples’ community. The effort anchors on the Zero Suicide initiative to address unique challenges presented by the Indian health system. The application period closed in February 2022.

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review.

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Svensson J. J Patient Saf. 2022;18:245-252.

Safety and quality of care for psychiatric patients is a relatively understudied area of patient safety research. This scoping review explores patient safety strategies used in psychiatry. The review identified seven key strategies that rely on staff performance, competence, and compliance – (1) risk management, (2) healthcare practitioners, (3) patient observation, (4) patient involvement, (5) computerized methods, (6) admission and discharge, and (7) security. These strategies primarily target reductions in suicide, self-harm, violence, and falls.

Suicide and suicide attempts on hospital grounds and clinic areas.

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Mills PD, Watts BV, Hemphill RR. J Patient Saf. 2021;17:e423-e428.

Researchers reviewed 15 years of root cause analysis reports of all instances of suicide and suicide attempts on Veterans Health Administration (VHA) grounds. Forty-seven suicides or suicide attempts were identified, and primary root causes included communication breakdown and a need for improved suicide interventions. The paper includes recommended actions to address the root causes of attempted and completed patient suicides.

Nurses as 'second victims' to their patients' suicidal attempts: a mixed-method study.

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Amit Aharon A, Fariba M, Shoshana F, et al. J Clin Nurs. 2021;30:3290-3300.

Patient suicide attempts or completions can have negative psychological impacts on the nurses involved. This mixed-methods study found a significant association between emotional distress and feeling alone with absenteeism and higher staff turnover. Healthcare organizations should develop support programs for second victims to increase resiliency and potentially decrease absenteeism and turnover.

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