Patient suicide in all settings is considered a never event. Nurses caring for the patient may experience negative psychological symptoms following inpatient suicide. This review identified five themes based on nurses’ psychological experiences: emotional experience, cognitive experience, coping strategies, self-reflection, and impact on self and practice. Hospital administrators should develop education and support programs to help nurses cope in the aftermath of inpatient suicide.  

This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.

This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.

After findings of gross negligence, the National Health Service (NHS) introduced ‘Freedom to Speak Up Guardians’ to lead safety culture change with the ultimate goal that speaking up about safety issues becomes the norm. The authors used semi-structured interviews with 51 individuals (e.g., Guardians, clinicians, policymakers/regulators, etc.) to describe the rollout of the Guardians. These interviews revealed that the role of the Guardians is rich in potential but that the initial narrow role of addressing only quality and safety concerns was not consistent with the myriad of complex issues brought to them and may indicate the need to expand the role definition.

This exploratory systematic review aimed to describe the state of the research on patient safety in inpatient mental health settings. Authors included 364 papers, representing 31 countries and data from over 150,000 participants. The existing research base was categorized into ten broad safety categories – interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorized leave, clinical decision making, falls, and infection prevention/control; papers were of varying quality with the majority of papers assessed as “fair”. The authors note that several areas of patient safety in inpatient mental health are particularly understudied, such as suicide, as the review only yielded one study meeting inclusion criteria.

Trigger tools allow for automated detection of patient harm from electronic health record data. Researchers developed and tested a 25-item trigger tool for mental health settings that identified virtually every adverse event that was found in confirmatory chart review. The authors suggest that this tool may advance safety efforts in inpatient mental health settings.

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.

Despite concerns regarding the safety and quality of care for hospitalized psychiatric patients, research exploring this area of patient safety is lacking. This commentary suggests several policy-focused strategies to improve the safety and patient-centeredness of inpatient psychiatric care, including payment reforms, incentive alignment, and increased funding for research.

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.

This study used focus groups to identify safety concerns voiced by inpatients on a psychiatric unit. Patients primarily expressed concern for their physical safety and expected nurses to ensure it.

Patient safety is a relatively new domain within the mental health field. This article describes the dominant issues and priorities for improving patient safety in this field based on a consensus conference.

This article describes the results from a group of international clinicians, researchers,and policymakers that identified undeveloped research areas in global patient safety.

The authors analyzed untoward events in psychiatric wards and found them more likely to coincide with a high male patient population, staff absences, and the occurrence of other incidents.