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Albutt AK, Berzins K, Louch G, et al. nt J Ment Health Nurs. 2021;30(3):798-810.
The UK’s National Health System has faced gaps in mental health care delivery affecting patient safety. Interviews with 14 mental health professionals identified several factors associated with patient safety in mental health service settings including safety culture, communication systems, service user factors, service process, and staff workload. Interventions to improve patient safety in mental health settings should be developed with these factors in mind.
Fröding E, Gäre BA, Westrin Å, et al. BMJ Open. 2021;11(3):e044068.
In Sweden, patient suicide following contact with a healthcare provider is regarded a potential case of patient harm and must be investigated and reported to the Swedish supervisory authority. This retrospective study analyzed reported cases across three timeframes and concluded the investigations were largely suited to fit the requirements of the supervisory authority rather than an opportunity for organizational learning to advance patient safety. A 2019 PSNet Spotlight Case highlights systems issues that contributed to a patient’s suicide following discharge from the Emergency Department.    

Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report No 19-08542-11.

Incomplete assessment of patient needs can miss opportunities to prevent patient harm. This report analyzes an incident where an intoxicated patient called a dedicated crisis support line yet preventive measures weren’t activated to avert an accidental overdose resulting in patient death. Recommendations for improvement include enhanced training for weekend and holiday staff, standardized safety plan development, and systemized internal review processes.