What near misses tell us about risk and safety in mental health care

Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review

OBJECTIVES

The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm.

METHOD

A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy.

RESULTS

The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization.

CONCLUSIONS

The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.

A retrospective analysis of near-miss incidents at a tertiary care teaching hospital in Riyadh, KSA

Objective

This study seeks to establish an error-free reporting system that enhances patient safety and organisational culture. It investigates the prevalence of near-miss incident reporting systems by healthcare professionals in the General Surgery Department.

Methods

This retrospective observational study was conducted at a tertiary care teaching hospital in Riyadh, KSA. A sample of 253 medical records, ranging from January 2018 to December 2020, belonging to secondary patients was obtained using the near-miss Datix reporting and occurrence variance reporting system. The demographic variable data of registered patients were based on their age group (18–80 years), length of stay, date of admission, medication prescribed for more than four days, and whether they underwent surgical interventions. The cases were documented after the occurrence of a near-miss incident using a convenience sampling technique.

Results

In terms of prevalence in the near-miss main categories, medical errors were 248 (98.2%), workplace violations were two (0.80%), and others was one (0.40%). The number of incidence in the subcategories were: prescribing, 227 (89.7%); dispensing, 16 (6.30%) wrong dose/strength, 118 (46.6%), male, 123 (48.6%), and female, 130 (51.4%). The mean age and S.D. of patients was 1.94 ± 0.88 years and the demographic nationality as 1.16 ± 0.37. The one-sample t-test value for the main categories was −235 (p-value < 0.001).

Conclusion

Near-misses are recognised as essential targets for continuous quality improvement tools to mitigate preoperative incidents in hospitals. These findings can benefit the advancement of techniques for improving guidelines related to compliance and effective communication to improve the preoperative safety of patients.

Nurses' Views Highlight a Need for the Systematic Development of Patient Safety Culture in Forensic Psychiatry Nursing

BACKGROUND

Although forensic nurses work with the most challenging psychiatric patients and manifest a safety culture in their interactions with patients, there have been few studies on patient safety culture in forensic psychiatric nursing.

OBJECTIVES

The aim of this qualitative study was to describe nurses' views of patient safety culture in their working unit and daily hospital work in 2 forensic hospitals in Finland.

METHODS

Data were collected over a period of 1 month by inviting nurses to answer an open-ended question in an anonymous Web-based questionnaire. A qualitative inductive analysis was performed on nurses' (n = 72) written descriptions of patient safety culture in state-owned forensic hospitals where most Finnish forensic patients are treated.

RESULTS

Six main themes were identified: "systematization of an open and trusting communication culture," "visible and close interaction between managers and staff," "nonpunitive responses to errors, learning and developing," "balancing staff and patient perspectives on safety culture," "operational safety guidelines," and "adequate human resources to ensure safety."

CONCLUSIONS

The findings highlight the influence of the prevailing culture on safety behaviors and outcomes for both healthcare workers and patients. Additionally, they underline the importance of an open culture with open communication and protocols.

Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study

BACKGROUND

Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery.

OBJECTIVE

To analyze all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017.

METHOD

We performed a descriptive retrospective study of near-miss incidents recorded in the hospital's electronic reporting system in a large non-profit hospital (497 beds). The results are expressed as absolute (n) and relative frequencies (%). Pearson's chi-square test, Fisher's exact test (Monte Carlo simulation) and linear regression were used.

RESULTS

A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift.

CONCLUSION

The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

Changes in patient safety culture: A patient safety intervention for Finnish forensic psychiatric hospital staff

AIM

To evaluate how a 3-year patient safety intervention, more specifically, the implementation of a patient safety incident reporting system, influences patient safety culture.

BACKGROUND

Positive patient safety culture improves both the quality of health care and patient safety. Nevertheless, nursing managers need tools that can help them develop and evaluate patient safety culture.

METHODS

The Hospital Survey on Patient Safety Culture was used to evaluate patient safety culture at two Finnish forensic psychiatric hospitals (study and control) over two periods, baseline and follow-up. Data were analysed using Z-score and T test statistics.

RESULTS

The follow-up results from the study hospital showed that five patient safety culture dimensions exhibited a significantly (p < 0.05) positive change in positive response rates over the 3-year period. Furthermore, nine out of twelve patient safety culture dimensions at the study hospital showed a significant improvement in mean score. At the control hospital, only the dimension of frequency of reporting events showed a significantly positive change (p < 0.05) in mean score.

CONCLUSION

This research shows that the studied patient safety intervention (implementation of the patient safety incident reporting system) significantly influences patient safety culture.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers should utilize a variety of patient safety interventions to improve patient safety and focus on leveraging information from patient safety incidents to advance patient safety culture.

The underreporting of medication errors: A retrospective and comparative root cause analysis in an acute mental health unit over a 3-year period

Medication errors remain a commonly reported clinical incident in health care as highlighted by the World Health Organization's focus to reduce medication-related harm. This retrospective quantitative analysis examined medication errors reported by staff using an electronic Clinical Incident Management System (CIMS) during a 3-year period from April 2014 to April 2017 at a metropolitan mental health ward in Western Australia. The aim of the project was to identify types of medication errors and the context in which they occur and to consider recourse so that medication errors can be reduced. Data were retrieved from the Clinical Incident Management System database and concerned medication incidents from categorized tiers within the system. Areas requiring improvement were identified, and the quality of the documented data captured in the database was reviewed for themes pertaining to medication errors. Content analysis provided insight into the following issues: (i) frequency of problem, (ii) when the problem was detected, and (iii) characteristics of the error (classification of drug/s, where the error occurred, what time the error occurred, what day of the week it occurred, and patient outcome). Data were compared to the state-wide results published in the Your Safety in Our Hands (2016) report. Results indicated several areas upon which quality improvement activities could be focused. These include the following: structural changes; changes to policy and practice; changes to individual responsibilities; improving workplace culture to counteract underreporting of medication errors; and improvement in safety and quality administration of medications within a mental health setting.

Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy

Although speaking up to protect patients is a key ethical and moral mandate for nurses, silence still prevails in many situations. On the basis of concepts of safety culture, generational theory, personal cultural literature, advocacy theory, oppressed group theory, and moral distress theory, the author conducted a literature review and offers a new theoretical framework. The proposed theory identifies primary factors of speaking up: generational, personal culture, and organizational.

Nursing Staff's Perceptions of Patient Safety in Psychiatric Inpatient Care

PURPOSE

This study aims to explore nursing staff's perceptions of patient safety in psychiatric inpatient care.

DESIGN AND METHODS

Nurses were asked to describe their perceptions in semi-structured interviews, and their responses were analyzed by inductive content analysis.

FINDINGS

Nurses addressed two sets of factors: one related to the experiences of safety and the other related to the implementation of safe care.

PRACTICE IMPLICATIONS

The views of the nurses contribute to formalization of organizational policies and strategies. In particular, they highlight the importance of continual training for the staff and management, considering patients' views, and treating patients as collaborators in their care.

Feasibility and Added Value of Executive WalkRounds in Long Term Care Organizations in the Netherlands

BACKGROUND

Currently available tools for the management of safety in health care are largely based on quantitative management information. Executive WalkRounds (WalkRounds [WR]) seems useful as a leadership tool to detect "soft signals"-alerts of unsafe situations or practices-and to enhance the mutual trust between frontline staff and the board of directors. The majority of the research on WR has been performed in hospitals. Therefore, a study was conducted to assess how the boards of directors of long term care organizations value WR as a leadership tool to perceive soft signals, and whether soft signals are of added value to enhance patient safety.

METHODS

WRs were introduced in a convenience sample of six organizations-two mental health care institutions, two nursing homes and home care organizations, and two institutions for the physically and intellectually disabled-between July 2012 and December 2013. Data were gathered from observation and reporting forms. Feasibility was evaluated by open-group interviews. A mixed-method analysis was performed using descriptive statistics and content analysis.

RESULTS

WRs were considered feasible, and the added value for the boards of directors consisted of an increased sense of urgency and safety awareness. The dialogue between the board of directors and frontline staff in each organization was essential for a collective patient safety culture. In total, WRs were used 68 times, and 298 soft signals were identified; most addressed care delivery and communication. Overall, 245 improvement activities were reported, of which 109 related to work environment.

CONCLUSION

WRs were considered useful and feasible for detecting soft signals in long term care organizations. These signals are valuable for enhancing patient safety and can be used by the board of directors in addition to the current quality management systems.

Toward a safer working environment on psychiatric wards: service users' delayed perspectives of aggression and violence-related situations and development ideas

PURPOSE

To explore service users' (n = 9) delayed perceptions of and suggestions for improvement of management of aggression/violence in psychiatry.

DESIGN AND METHOD

Focus group interviews, inductive content analysis.

FINDINGS

Participants reported aggression/violence-related negative perceptions (including loneliness, boredom, excessive control, and fear) but also memories of humane and caring personnel. The suggestions included meaningful activities and humane, interactive nursing.

PRACTICE IMPLICATIONS

Delayed perceptions and proposals resembled the proximate ones. Perceptions may persist for years. Such perceptions and proposals, if taken into account from the beginning of treatment, may prevent negative long-term consequences of witnessed or experienced aggression/violence. Humane, interactive nursing models should be studied and disseminated.