The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
Archer S, Thibaut BI, Dewa LH, et al. J Psychiatr Ment Health Nurs. 2019;27:211-223.
Researchers conducted focus groups in this qualitative study of staff in mental healthcare settings and assessed the barriers and facilitators to incident reporting. The authors identified unique challenges to incident reporting in mental health, including the incidence of violence and aggressive behavior. Participants often underreported violent or aggressive events because they attributed the behavior to the patient’s diagnosis, and cited dissatisfaction with how reported incidents were handled by police.
Mokkenstorm JK, Kerkhof AJFM, Smit JH, et al. Suicide Life Threat Behav. 2018;48:745-754.
Suicide in all settings is considered a sentinel event. This commentary describes an aspirational suicide eradication program. The approach combines direct identification of suicidal behavior and treatment, system-focused process improvements, and organizational safety culture as interdependent strategies for eliminating suicide. A previous WebM&M commentary discussed a suicide attempt on an inpatient medical unit.
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.
Cleary M, Lees D, Lopez V. Issues Ment Health Nurs. 2018;39:980-982.
Effective apology behaviors improve opportunities for error resolution for clinicians, patients, and families. This commentary highlights the importance of expressing empathy, considering legal implications, and demonstrating individual, leadership, and organizational support of open disclosure.
Williams SC, Schmaltz SP, Castro GM, et al. Jt Comm J Qual Patient Saf. 2018;44:643-650.
The Joint Commission identifies inpatient suicide as a sentinel event. Little is known about the epidemiology of hospital suicides other than that they are rare and occur mostly in psychiatry wards. Researchers examined two national databases to develop the first data-driven appraisal of hospital suicide rates. Nationally, between 49 and 65 hospital suicides occur each year. Nearly 75% happen during psychiatric treatment, and the most common means of death is hanging. This hospital suicide rate is an order of magnitude lower than prior estimates. An accompanying editorial raises concerns about the much larger epidemic of suicide immediately after psychiatric hospital discharge. A prior WebM&M commentary highlighted additional strategies to reduce hospital suicide risk.
Incident reporting systems are widely implemented in health care systems, but they are often underutilized by clinicians. This institution implemented a psychiatry-specific incident reporting tool. Researchers found that physicians submitted more incident reports but there was no significant change in how many serious harm events were identified. An Annual Perspective described the challenges in measuring and responding to serious patient harm.
Reilly CA, Cullen SW, Watts B, et al. Jt Comm J Qual Patient Saf. 2019;45:63-69.
A number of studies have shown that incident reporting systems only capture a small proportion of suspected adverse events in hospitals. Conducted in inpatient psychiatric units at Veterans Affairs hospitals, the study found that only a minority of adverse events identified through chart review were voluntarily reported by clinicians. A recent commentary discussed the inherent limitations of incident reporting systems and suggested ways to optimize their utility.
Patients with mental health concerns are vulnerable to harm from medication errors. This investigation report describes factors that contributed to the deaths of two psychiatric inpatients and identifies weaknesses in monitoring, polypharmacy review, and off-label medication use as primary concerns.
True G, Frasso R, Cullen SW, et al. Gen Hosp Psychiatry. 2017;48:65-71.
This individual interview study of staff at Veterans Health Administration inpatient psychiatry units identified several factors that affect patient safety in this setting, including safety culture, leadership engagement, and patient-centeredness. The authors advocate for a multistakeholder approach that engages frontline staff and leadership in order to improve patient safety for inpatient psychiatric care.
Alshehri GH, Keers RN, Ashcroft DM. Drug Saf. 2017;40:871-886.
Medication errors represent a significant source of patient harm, and patients with mental health diagnoses may be particularly vulnerable. This systematic review found that medication errors and adverse drug events in mental health hospitals are common.
Keers RN, Williams SD, Vattakatuchery JJ, et al. J Clin Pharm Ther. 2015;40:645-54.
In this study, prospective pharmacist review of written prescriptions for adults discharged from mental health hospitals found that about 20% contained medication errors. These findings underscore the risks of adverse events in the postdischarge period and the need for more oversight of discharge prescriptions.
Chasnoff IJ, Wells AM, King L. Pediatrics. 2015;135:264-70.
Diagnostic errors are a known cause of preventable adverse events. The vast majority of children ultimately determined to have fetal alcohol spectrum disorder in this cohort study had been previously misdiagnosed, despite having undergone clinical evaluation for developmental or behavioral problems.
Haw C, Stubbs J, Dickens GL. J Psychiatr Ment Health Nurs. 2014;21:797-805.
Researchers interviewed mental health nurses to determine perceived obstacles to reporting medication administration errors or near misses. Many factors were identified, including insufficient knowledge, fear of consequences, or burden of work associated with reporting. These have also been cited as reasons for under-reporting of errors in prior nursing studies.
Lee A, Mills PD, Watts B. Gen Hosp Psychiatry. 2012;34:304-11.
This study reviewed 75 root cause analyses from the Veterans Health Administration system to highlight common activities during falls and frequent contributing factors. Getting up from a bed or chair was the most common activity, whereas environmental hazards and poor communication of fall risk were the most common contributing factors.
Adverse drug events have been documented as a significant problem in inpatient psychiatric facilities, but methods of preventing errors in this setting have not been researched. This study, conducted at an academic inpatient psychiatric hospital, combined a computerized provider order entry system with a structured event reporting system that was used by physicians, nurses, and pharmacists. Implementation of the system was associated with a significant reduction in both prescribing errors and medication administration errors over a 5-year period.
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