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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. 
Svensson J. J Patient Saf. 2021;Epub Aug 5.
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.
Mills PD, Watts BV, Hemphill RR. J Patient Saf. 2021;17(5):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.
Amit Aharon A, Fariba M, Shoshana F, et al. J Clin Nurs. 2021;30(21-22):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.
Shao Q, Wang Y, Hou K, et al. J Adv Nurs. 2021;77(10):4005-4016.
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.  
Berg SH, Rørtveit K, Walby FA, et al. BMJ Open. 2020;10(11):e040088.
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.   
Donovan AL, Aaronson EL, Black L, et al. Jt Comm J Qual Patient Saf. 2021;47(1):23-30.
Patient suicide, attempted suicide, or self-harm are considered ‘never events.’ This article describes the development and implementation of a safety protocol for emergency department (ED) patients at risk for self-harm, including the creation of safe bathrooms and increasing the number of trained observers in the ED. Implementation of the protocol was correlated with lower rates of self-harm.  

Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30(7):567-576.
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.
Wyder M, Ray MK, Roennfeldt H, et al. Int J Qual Health Care. 2020;32(5):285-291.
This systematic review examined common systems factors affecting suicide deaths in mental health care. Seven themes contributing to suicide deaths were identified: (1) inappropriate or incomplete risk assessment; (2) lack of family involvement; (3) inadequate transitions and communication between different care teams; (4) lack of adherence to policies and procedures; (5) treatment not in line with current guidelines; (6) access to means and observation and; (7) lack of specialist services within the community.
Gill S, Mills PD, Watts BV, et al. J Patient Saf. 2021;17(8):e898-e903.
This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency departments at Veterans Health Administration hospitals over a two-year period. Of the 144 cases identified, the majority involved delays in care (26%), elopements (15%), suicide attempts and deaths (10%), inappropriate discharges (10%) and errors following procedures (10%). RCA revealed that primary contributory factors leading to adverse events were knowledge/educational deficits (11%) and policies/procedures that were either inadequate (11%) or lacking standardization (10%).
Frost DA, Snydeman CK, Lantieri MJ, et al. Psychosomatics. 2019;61(2):154-160.
This study assessed the effectiveness of a suicide prevention checklist in a single hospital developed based on Joint Commission recommendations. In the two years following checklist implementation, suicide attempts decreased by 42% (compared to the preceding two years); the number of patients sustaining temporary or minor injuries also decreased by 57% across the same time period. Survey responses showed that unit nurses felt the checklist list created a safe environment (88%) and that it supported consistent practice (90%) of caring for potentially suicidal patients in nonpsychiatric units.
Glauser G, Goodrich S, McClintock SD, et al. J Thorac Cardiovasc Surg. 2021;162(1):155-164.e2.
Surgical overlap is a longstanding practice, and reports suggest a link to postoperative complications and patient safety. This study measured the impact of overlap on patient outcomes among patients undergoing cardiac surgical interventions over a two-year period and found that overlap did not predict mortality, readmission, reoperation or emergency department visits at 30- or 90-days post-discharge, compared to patients without surgical overlap.
Quinlivan L, Littlewood DL, Webb RT, et al. J Mental Health. 2020;29(1):1-5.
This editorial proposes ad adapting a patient safety paradigm – Safety-I or Safety-II – to provide insights into suicidal behavioral, as it is a preventable outcome and health services play an important role in reducing its incidence. The new paradigm – Safety III – would incorporate on health services research combined with ethnography and strong patient/public involvement.
Thibaut BI, Dewa LH, Ramtale SC, et al. BMJ Open. 2019;9(12):e030230.
This exploratory systematic review aimed to describe the state of the research on patient safety in inpatient mental health settings. Authors included 364 papers, representing 31 countries and data from over 150,000 participants. The existing research base was categorized into ten broad safety categories – interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorized leave, clinical decision making, falls, and infection prevention/control; papers were of varying quality with the majority of papers assessed as “fair”. The authors note that several areas of patient safety in inpatient mental health are particularly understudied, such as suicide, as the review only yielded one study meeting inclusion criteria.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No. 19-00468-67.
Systemic weaknesses challenge safe care in Veterans Affairs health systems facilities. This report analyzed a patient suicide at one medical center and determined contributors to the failure. This report shares recommendations to address deficiencies including improved communication across the care continuum and reliably acting on root cause analysis results.
Oakbrook Terrace, IL: Joint Commission: October 2019.
Inpatient suicide is increasing as a safety concern. This case analysis offers two levels of examination of a hypothetical patient suicide: one that outlines points of failure in the patient’s care and the other that shares strategies to prevent the event from occurring. 
The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable. While most are rare, when never events occur, they are devastating to patients and indicate serious underlying organizational safety problems.