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.
Anderson E, Mohr DC, Regenbogen I, et al. J Patient Saf. 2021;17:316-322.
Burnout and low staff morale have been associated with poor patient safety outcomes. This study focused on the association between organizational climate, burnout and morale, and the use of seclusion and restraints in inpatient psychiatric hospitals. The authors recommend that initiatives aimed at reducing restraints and seclusion in inpatient psychiatric facilities also include a component aimed at improving organizational climate and staff morale.
Articles in this special issue report on initiatives undertaken by the Canadian National Patient Safety Consortium with a focus on the effect patient partnerships on initiative priority areas including never events, safety culture and homecare safety improvements.
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.
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.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMJ Open Qual. 2018;7:e000433.
Establishing a culture of safety within health care organizations requires strong leadership support. This cross-sectional survey study of nurses, allied health professionals, and unit clerks working in the inpatient setting at a single hospital found that positive perceptions of senior leadership support for safety and positive perceptions of teamwork were associated with positive perceptions of patient safety. In addition, when staff perceived senior leadership support for safety to be lacking, the positive impact of direct managerial leadership on staff perceptions of patient safety was more pronounced.
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.
Keers RN, Plácido M, Bennett K, et al. PLoS One. 2018;13:e0206233.
This interview study used a human factors method, the critical incident technique, to identify underlying factors in medication administration errors in a mental health inpatient facility. The team identified multiple interconnected vulnerabilities, including inadequate staffing, interruptions, and communication challenges. The findings underscore the persistence of widely documented medication safety administration concerns.
O'Connor K, Neff DM, Pitman S. Eur Psychiatry. 2018;53:74-99.
Clinician burnout has been associated with decreased job satisfaction. Burnout may also be detrimental to patient safety. This systematic review and meta-analysis found high rates of burnout among mental health professionals. The authors recommend strategies to address burnout including promoting professional autonomy, developing teamwork, and providing quality clinical supervision.
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.
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.
Kanerva A, Lammintakanen J, Kivinen T. Perspect Psych Care. 2016;52:25-31.
Although patient safety has been a focus of nursing care in hospitals, this study found significant gaps in nurses' perceptions of patient safety in psychiatric inpatient units. For example, none of the interviewed nurses mentioned the importance of preventing inpatient suicide, which was the topic of a recent Joint Commission sentinel event alert.
Hemingway S, McCann T, Baxter H, et al. Int J Nurs Pract. 2015;21:733-40.
Medication errors are common in mental health care. This survey of nurses and nursing students identified interruptions and insufficient medication knowledge as major barriers to ensuring medication safety in outpatient mental health.
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.
Mills PD, King LA, Watts B, et al. Gen Hosp Psych. 2013;35:528-536.
This study examined inpatient suicides at Veterans Affairs hospitals and provided recommendations for mitigating risks. Hanging by using equipment present in psychiatric wards was the most common method of suicide.
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.
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