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Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings
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    • An 18-year-old man with a history of untreated depression and suicide attempts (but no history of psychiatric hospitalizations) was seen in the ED for suicidal ideation after recent gun purchase. Due to suicidal ideation, he was placed on safety hold and a psychiatric consultation was requested. The psychiatry team recommended discharge with outpatient therapy; he was discharged with outpatient resources, the crisis hotline phone number, and strict return precautions.

    The benefits and harms of open notes in mental health: a Delphi survey of international experts.
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    • Blease CR, Kharko A, Hägglund M, et al. PLoS ONE. 2021;16(10):e0258056.
    Allowing patients to access their own ambulatory clinical health record has benefits such as identification of errors and increased trust. This study focused on risks and benefits of patient access to mental health care records. Experts suggested the benefits would be similar to those seen in primary care, such as increased patient engagement, with the potential additional benefit of reduced stigmatization.
    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. 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.
    Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care.
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    • National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021

    System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergent and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.
    Preventing pregnancy-related mental health deaths: insights from 14 US maternal mortality review committees, 2008-17.
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    • Trost SL, Beauregard JL, Smoots AN, et al. Health Aff (Millwood). 2021;40(10):1551-1559.
    Missed diagnosis of mental health conditions can lead to serious adverse outcomes. Researchers evaluated data from 2008 to 2017 from 14 state Maternal Mortality Review Committees and found that 11% of pregnancy-related deaths were due to mental health conditions. A substantial proportion of people with a pregnancy-related mental health cause of death had a history of depression or past/current substance use. Researchers conclude that addressing gaps maternal mental health care is essential to improving maternal safety.
    Patient safety and mental health-a growing quality gap in Canada.
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    • Waddell AE, Gratzer D. Can J Psychiatry. 2021:070674372110365.
    Safety gaps in mental health care offers a limited view if focused primarily on patient suicide. This commentary calls for Canadian psychiatric professionals to examine the safety of their patients from a system perspective to develop a research and practice improvement strategy.
    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(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.
    Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.
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    • Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17(5):341-351.
    … J Patient Saf … Medication errors are common in mental health hospitals. This study found medication administration … GH, Keers RN, Carson-Stevens A, et al. Medication safety in mental health hospitals: a mixed-methods analysis of …
    Analysis of suicides reported as adverse events in psychiatry resulted in nine quality improvement initiatives.
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    • Mackenhauer J, Winsløv J-H, Holmskov J, et al. Crisis. 2021;Epub May 19.
    Prior research has found that patients who die by suicide often had recent contact with the healthcare setting. Based on a multi-year chart review at one institution, the authors concluded that suicide risk assessment and documentation in the heath record to be insufficient. The authors outline quality improvement recommendations focused on improving documentation, suicide assessment and intervention training, and improving communications with families, caregivers, and other health care providers.
    Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.
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    • Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

    This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.
    “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV)
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    • The Behavioral Health Vital Signs (BHVS) screener is a patient questionnaire input into the electronic health record for depressive symptoms, alcohol and substance use, and interpersonal violence. Widespread staff education and a standardized workflow were developed to ensure that BHVS was implemented in all primary care clinics within the San Francisco Health Network. As a result of implementation, screening for IPV greatly increased, and healthcare teams learned about how to provide patients with resources and referrals regardless of IPV disclosure (“Universal Education”), resulting in more patients referred to support services.

    Enhancing psychological safety in mental health services.
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    • Hunt DF, Bailey J, Lennox BR, et al. Int J Ment Health Syst. 2021;15(1):33.
    Psychological safety has been widely studied in a variety of settings, clinical areas, and patient outcomes. This commentary lays out the benefits of safety culture and how it can be implemented organization-wide, with a particular focus on mental health organizations. Specific interventions are discussed, including family involvement, leadership communication, and simulation.
    Detecting and assessing suicide ideation during the COVID-19 pandemic.
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    • Simon GE, Stewart CC, Gary MC, et al. Jt Comm J Qual Patient Saf. 2021;47(7):452-457.
    … Patient Saf … The COVID-19 pandemic expanded the use of telehealth and virtual care . This article describes one health system’s experience … assessment of suicide risk among patients receiving virtual mental health care. … Simon GE, Stewart CC, Gary MC, et al. …
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