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Search results for "Health Care Executives and Administrators"

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Journal Article > Study

Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.

Riblet N, Shiner B, Watts BV, Mills P, Rusch B, Hemphill RR. J Nerv Ment Dis. 2017;205:436-442.

This review of root cause analysis reports about suicide within 7 days of discharge from inpatient mental health facilities determined that most cases of suicide occurred prior to scheduled outpatient postdischarge follow-up. Many patients who went on to die by suicide left against medical advice but did not meet criteria to be held against their wishes, highlighting the conflict between safety and patient autonomy.

Journal Article > Study

Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims.

Quinn PD, Hur K, Chang Z, et al. Pain. 2017;158:140-148.

Opioid medications are associated with an increased risk of adverse drug events, including overdose. Certain populations may be at greater risk for adverse outcomes from opioids and may be more likely to receive them. This study looked at health insurance claims data for more than 10 million patients who filled opioid prescriptions. Researchers found that those with underlying psychiatric and behavioral conditions (including opioid and nonopioid substance use disorders) were more likely to receive long-term opioid therapy than patients without such conditions.

Newspaper/Magazine Article

Safety for all: integrated design for inpatient units.

Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.

Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for psychiatric patients must make unique considerations to protect this vulnerable population from harming themselves and other individuals that come into contact with them. This magazine article provides recommendations for hospitals to enhance room and fixture designs to reduce risks for mental health patients.

Journal Article > Study

PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors.

Mariano MT, Brooks V, Digiacomo M. Jt Comm J Qual Patient Saf. 2016;42:316-320.

This study describes a quality improvement project to enhance handoffs among psychiatry residents. The use of a mnemonic PSYCH (Patient information, Situation leading to hospitalization, Your assessment, Critical information, and Hindrance to discharge) led to more complete and efficient handoffs, consistent with other studies of structured handoff communications.

Journal Article > Study

Patient safety events and harms during medical and surgical hospitalizations for persons with serious mental illness.

Daumit GL, McGinty EE, Pronovost P, et al. Psychiatr Serv. 2016;67:1068-1075.

Patients with serious psychiatric disorders, such as schizophrenia and bipolar disorder, often require high-risk medications and experience medical comorbidities. This cohort study assessed the frequency of preventable adverse events during medical hospitalizations in patients with serious mental illness. Preventable adverse events, primarily medication errors, were very common among these patients and were associated with physical injury during hospitalization. The study could not assess the causes of the adverse events, but prior studies have shown that medication administration errors are frequent in psychiatric inpatients. A WebM&M commentary discussed a case of a preventable death occurring shortly after a patient with schizophrenia was discharged from a medical hospitalization.

Journal Article > Study

Clinical outcomes and mortality associated with weekend admission to psychiatric hospital.

Patel R, Chesney E, Cullen AE, et al. Br J Psychiatry. 2016;209:29-34.

Multiple studies have documented that patients with various conditions admitted over the weekend have worse outcomes than those admitted on a weekday. This large retrospective study did not find any difference in inpatient mortality for patients admitted to a psychiatric ward on the weekend. However, these patients had shorter admissions and were more likely to be readmitted, and the authors felt that these findings were most likely attributable to inherent differences in the types of psychiatric patients admitted on weekends.

Journal Article > Study

Missing clinical and behavioral health data in a large electronic health record (EHR) system.

Madden JM, Lakoma MD, Rusinak D, Lu CY, Soumerai SB. J Am Med Inform Assoc. 2016;23:1143-1149.

Electronic health records (EHRs) were promoted as a patient safety improvement strategy, but their promise has not been fully realized. Comparing data from an EHR to information from insurance claims, this study found that EHRs inadequately capture mental health care, including inpatient and outpatient visits, medications, and specialty care. This information gap carries significant risk to patients and suggests a need for improved care integration and EHR interoperability.

Journal Article > Study

Pharmacist medication reviews to improve safety monitoring in primary care patients.

Gallimore CE, Sokhal D, Zeidler Schreiter E, Margolis AR. Fam Syst Health. 2016;34:104-113.

In this study performed in a community behavioral health center, medication reviews by pharmacists helped improve appropriate monitoring of patients prescribed high-risk psychotropic medications. A WebM&M commentary describes a case of a potentially harmful medication error in an outpatient psychiatry clinic.

Journal Article > Review

The impact of resident duty hour and supervision changes: a review.

Greenberg WE, Borus JF. Harv Rev Psychiatry. 2016;24:69-76.

The benefits of duty hour restrictions have been debated since their implementation. This review provides an overview of the controversy surrounding duty hour limits and discusses how the restrictions affect psychiatry residents. Highlighting concerns regarding residents feeling less prepared for senior roles and having insufficient time to spend with patients, the authors suggest that further research is needed to understand the impact of resident duty hours on patient safety.

Journal Article > Study

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

Keers RN, Williams SD, Vattakatuchery JJ, et al. J Clin Pharm Ther. 2015;40:645-654.

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.

Journal Article > Commentary

Making health care safer: what is the contribution of health psychology?

Vincent C, Wearden A, French DP. Br J Health Psychol. 2015;20:681-687.

This commentary discusses behavior change, error disclosure, team communication, decision making, and organizational culture as components of health care where psychology can enhance safety. The authors advocate for increased engagement of health psychologists in patient safety improvement.

Journal Article > Commentary

Virginia Tech as a sentinel event: the role of psychiatry in managing emotionally troubled students on college and university campuses.

Giggie MA. Harv Rev Psychiatry. 2015;23:413-425.

Exploring a sentinel event at a college involving a student with mental health issues, this commentary highlights complex psychological problems among students on college campuses and the need for college psychiatrists to better understand confidentiality policies. The author advocates for a more robust process for involving psychiatrists in the care of troubled students could help to prevent large-scale system failures.

Book/Report

Diagnostic experiences of children with attention-deficit/hyperactivity disorder.

Visser SN, Zablotsky B, Holbrook JR, Danielson ML, Bitsko RH. Natl Health Stat Report. 2015;(81):1-8.

This survey of parents of children with attention-deficit/hyperactivity disorder examined how this diagnosis was established. There was variation in the diagnostic process, including testing methods and types of practitioners involved (primary care physician, psychologist, psychiatrist). These results demonstrate the inherent challenge of diagnosing a heterogeneous condition even when diagnostic guidelines and criteria exist.

Journal Article > Study

A prospective study of suicide screening tools and their association with near-term adverse events in the ED.

Chang BP, Tan TM. Am J Emerg Med. 2015;33:1680-1683.

Suicidal ideation is a challenging clinical problem in the emergency department. This prospective study found that commonly used suicide screening questionnaires did not predict which patient would require unscheduled psychiatric evaluation, sedating medications, or physical restraints. These results highlight the need for improved tools to identify which patients are most at risk for instability in the emergency department.

Journal Article > Study

The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best model for error investigation in mental health services.

Vrklevski LP, McKechnie L, O'Connor N. J Patient Saf. 2015 Mar 26; [Epub ahead of print].

Root cause analysis is a longstanding approach to in-depth investigation of adverse events, with evidence supporting its use in identifying underlying causes of safety problems. Reviewing for mental health events, mostly suicides and homicides, researchers found that recommendations often echoed existing policy and were not implemented. While the authors assert that the method may not be helpful, their findings also emphasize the importance of implementing root cause analysis recommendations in order to augment safety.

Journal Article > Study

Communication elements supporting patient safety in psychiatric inpatient care.

Kanerva A, Kivinen T, Lammintakanen J. J Psychiatr Ment Health Nurs. 2015;22:298-305.

In this study, researchers interviewed psychiatric nurses to explore how they conceptualize communication that contributes to patient safety in the inpatient psychiatric setting. A similar approach was used in an earlier study to identify how patients on such units viewed safety issues.

Journal Article > Study

Nursing staff's perceptions of patient safety in psychiatric inpatient care.

Kanerva A, Lammintakanen J, Kivinen T. Perspect Psychiatr 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.

Journal Article > Study

Medication-administration errors in an urban mental health hospital: a direct observation study.

Cottney A, Innes J. Int J Ment Health Nurs. 2015;24:65-74.

In this prospective observational study at a psychiatric hospital, errors were identified in 3% of medication administration episodes, with omission being the most common error type. As in prior studies, interruptions and higher patient volume were associated with increased risk of mistakes.

Journal Article > Study

Residency training in handoffs: a survey of program directors in psychiatry.

Arbuckle MR, Reardon CL, Young JQ. Acad Psychiatry. 2015;39:132-138.

According to this survey study, a substantial minority of psychiatry residency training programs reported that they did not provide formal training in handoffs, which is now required by the Accreditation Council for Graduate Medical Education. Barriers to developing such training included difficulty attaining buy-in from clinicians and standardizing handoffs across different sites.

Journal Article > Study

The perceptions of nurses towards barriers to the safe administration of medicines in mental health settings.

Hemingway S, McCann T, Baxter H, Smith G, Burgess-Dawson R, Dewhirst K. Int J Nurs Pract. 2015;21:733-740.

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.

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