Wyder M, Ray MK, Roennfeldt H, et al. Int J Qual Health Care. 2020;32:285-291.
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.
System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone.
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