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Search results for "Psychiatric Facilities"

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Book/Report

Adverse Health Events in Minnesota: 15th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; March 2019.

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 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.

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. 2018;14:41-48.

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

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

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.

Journal Article > Study

Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital.

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.

Journal Article > Study

'Safe enough in here?': Patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward.

Stenhouse RC. J Clin Nurs. 2013;22:3109-3119.

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.

Journal Article > Study

Using root cause analysis to reduce falls with injury in the psychiatric unit.

Lee A, Mills PD, Watts BV. Gen Hosp Psychiatry. 2012;34:304-311.

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.

Newspaper/Magazine Article

Hospital mistakes kept secret.

Judd A. The Atlanta Journal-Constitution. November 20, 2011.

Discussing a case of patient suicide, this news article explores the lack of transparency around patient safety incidents in the state of Georgia.

Journal Article > Study

Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism.

Jayaram G, Doyle D, Steinwachs D, Samuels J. J Psychiatr Pract. 2011;17:81–88.

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.

Journal Article > Study

Toward understanding errors in inpatient psychiatry: a qualitative inquiry.

Cullen SW, Nath SB, Marcus SC. Psychiatr Q. 2010;81:197-205.

The authors used focus groups and interviews to develop a taxonomy of errors in inpatient psychiatry and explore underlying systems causes of the errors. Medication errors, diagnostic errors, and failure to prevent patient harm (such as suicide attempts) were among the common types of errors identified.

Journal Article > Study

Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely.

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.

Journal Article > Commentary

Global priorities for patient safety research.

Bates DW, Larizgoitia I, Prasopa-Plaizier N, Jha AK; Research Priority Setting Working Group of the WHO World Alliance for Patient Safety. BMJ. 2009;338:b1775.

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

Journal Article > Study

An observational study of medication administration errors in old-age psychiatric inpatients.

Haw C, Stubbs J, Dickens G. Int J Qual Health Care. 2007;19:210-216.

The researchers observed clinical staff administering medications in an elderly psychiatric patient population and saw that errors were common yet rarely of serious clinical consequence.

Journal Article > Study

Medication safety in a psychiatric hospital.

Rothschild JM, Mann K, Keohane CA, et al. Gen Hosp Psychiatry. 2007;29:156-162.

The authors analyzed the incidence and type of medication errors and adverse drug events in a psychiatric hospital. They found that errors were common in this setting and were frequently associated with physician orders.

Journal Article > Study

Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: the Tompkins Acute Ward Study.

Bowers L, Allan T, Simpson A, Nijman H, Warren J. Int J Soc Psychiatry. 2007;53:75-84.

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.

Journal Article > Study

A review of medication administration errors reported in a large psychiatric hospital in the United Kingdom.

Haw CM, Dickens G, Stubbs J. Psychiatr Serv. 2005;56:1610-1613.

The investigators analyzed incident reports from a 42-month period and found that both environmental and personal factors played a key role in the medication errors and near misses reported.

Journal Article > Study

Interception of potential adverse drug events in long-term psychiatric care units.

Sawamura K, Ito H, Yamazumi S, Kurita H. Psychiatry Clin Neurosci. 2005;59:379-384.

The authors analyzed incident reports from Japanese long-term care psychiatric units to understand the relationship between environmental, organizational, and human factors elements of drug administration and how they affect the interception of errors.

Cases & Commentaries

Spotlight: Mistaken Attribution, Diagnostic Misstep

  • Spotlight Case
  • CE/MOC
  • Web M&M

Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD; January 2019

A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone. She was transferred to the ICU of the hospital, where a chest CT scan revealed bilateral pulmonary emboli (explaining the tachycardia and hypoxia), and clinicians also diagnosed neuroleptic malignant syndrome (a rare and life-threatening reaction to some psychiatric medications).

Book/Report

Opening the Door to Change. NHS Safety Culture and the Need for Transformation.

Newcastle upon Tyne, UK: Care Quality Commission; December 2018.

The term never events was originally coined to describe rare, devastating, and preventable events. This report provides an analysis of National Health Service (NHS) efforts to optimize use of alerts, guidance, and recommendations to prevent never events. The investigation found that NHS staff feel unsupported by training, challenged by complex processes of care to practice safely, and uncertainty regarding improvement roles at the system level.

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