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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.
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.
Berzins K, Baker J, Louch G, et al. Health Expect. 2020;23:549-561.
This qualitative study interviewed patients and caregivers about their experiences and perceptions of safety within mental health services. These interviews identified a broad range of safety issues; the authors suggest that patient safety in mental health services could be expanded to include harm caused trying to access services and self-harm provoked by contact with, or rejection from, services.
Cullen SW, Xie M, Vermeulen JM, et al. Med Care. 2019;57:913-920.
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.

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Vermeulen JM, Doedens P, Cullen SW, et al. Psychiatr Serv. 2018;69:1087-1094.
Prior research has shown that numerous factors may impact patient safety in the inpatient psychiatry setting. In this study involving 4371 patients admitted to 14 inpatient psychiatric units at acute care general hospitals, researchers found that older patients and those with longer length of stay were at increased risk for adverse events and medical errors.
Grantham D. Behavioral healthcare. 2010;30:22-4.
This news article highlights an award-winning addiction treatment center’s strategy to embrace patient safety improvement.
Young JQ, Wachter RM. Jt Comm J Qual Patient Saf. 2009;35:439-448.
This study describes the application of Toyota Production System principles, which emphasize designing standardized and reliable work processes by an iterative process of testing and evaluation, to improving patient safety and continuity of care at a psychiatric institution.
Lankshear A, Lowson K, Harden J, et al. J Adv Nurs. 2008;63.
This study demonstrated that simply designing "system" safeguards fails to prevent errors in subsequent monitoring and implementation. Investigators used three safety alerts, including latex allergy, as markers of how well these alerts were being adopted in practice by bedside nurses.
A young woman with borderline personality disorder hospitalized following a suicide attempt is allowed to leave the hospital and attempts suicide again.