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.

Ambulatory care settings are receiving increased attention as a focus for patient safety improvements. Using data from a multistate patient safety organization (PSO) database, the researchers sought to characterize patterns and characteristics of patient safety incidents reported in ambulatory care settings. Analyses found that 5.9% of events resulted in severe harm and 1.9% resulted in patient death. Over half of the events were from outpatient subspecialty care; fewer events occurred in home/community (5.2%), primary care (2.1%), or dialysis (2.0%) settings. Medication-related events were most common, followed by clinical deterioration and falls. Predictors of higher harm included diagnostic errors, patient/caregiver challenges, and events occurring in home/community or psychiatric settings. These results can help ambulatory care settings target safety events and develop systems-level prevention strategies.  

This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.

Various factors can impact patient safety risk in psychiatric settings. This study assessed the prevalence of AEs and MEs in community hospitals and Veterans Health Administration (VHA) hospitals and found that psychiatric inpatients at community hospitals were twice as likely to experience these patient safety events than VHA inpatients, even after controlling for patient and hospital characteristics.

The Joint Commission identifies inpatient suicide as a sentinel event. Little is known about the epidemiology of hospital suicides other than that they are rare and occur mostly in psychiatry wards. Researchers examined two national databases to develop the first data-driven appraisal of hospital suicide rates. Nationally, between 49 and 65 hospital suicides occur each year. Nearly 75% happen during psychiatric treatment, and the most common means of death is hanging. This hospital suicide rate is an order of magnitude lower than prior estimates. An accompanying editorial raises concerns about the much larger epidemic of suicide immediately after psychiatric hospital discharge. A prior WebM&M commentary highlighted additional strategies to reduce hospital suicide risk.

Diagnostic errors are a known cause of preventable adverse events. The vast majority of children ultimately determined to have fetal alcohol spectrum disorder in this cohort study had been previously misdiagnosed, despite having undergone clinical evaluation for developmental or behavioral problems.

Researchers interviewed mental health nurses to determine perceived obstacles to reporting medication administration errors or near misses. Many factors were identified, including insufficient knowledge, fear of consequences, or burden of work associated with reporting. These have also been cited as reasons for under-reporting of errors in prior nursing studies.

This study examined inpatient suicides at Veterans Affairs hospitals and provided recommendations for mitigating risks. Hanging by using equipment present in psychiatric wards was the most common method of suicide.

Adverse drug events have been documented as a significant problem in inpatient psychiatric facilities, but methods of preventing errors in this setting have not been researched. This study, conducted at an academic inpatient psychiatric hospital, combined a computerized provider order entry system with a structured event reporting system that was used by physicians, nurses, and pharmacists. Implementation of the system was associated with a significant reduction in both prescribing errors and medication administration errors over a 5-year period.

The authors used focus groups and interviews to develop a taxonomy of errors in inpatient psychiatry and explore underlying systems causes of the errors. Medication errors, diagnostic errors, and failure to prevent patient harm (such as suicide attempts) were among the common types of errors identified.

The Department of Veterans Affairs has pioneered the use of root cause analysis to identify systems causes of adverse events. This study reports on the use of this technique to analyze inpatient suicide attempts at VA hospitals. Suicide attempts, the majority of which occur on inpatient psychiatric units, are considered a health care never event. Review of root cause analysis reports over a 7-year period identified several methods of self-harm and factors that facilitated suicide attempts. A prior study reported on preventive mechanisms that have been implemented at VA hospitals to reduce the risk of inpatient suicide attempts.

The authors describe a clinical pharmacy service that monitors patients on high-alert medications to prevent adverse events and improve the safety of medication administration.

The authors analyzed the incidence and type of medication errors and adverse drug events in a psychiatric hospital. They found that errors were common in this setting and were frequently associated with physician orders.