Impact of over-the-door alarms: Root cause analysis review of suicide attempts and deaths on veterans health administration mental health units

Mills, Peter D.; Soncrant, Christina; Bender, John A.; Gunnar, William

doi:10.1016/j.genhosppsych.2020.01.005

Cited by 4 publications

(9 citation statements)

References 6 publications

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“…Like Watts et al, 30 Mills et al 32 reported that the leading root cause for suicides was related to Environment/Equipment (28%); hanging (46%) was the most common method, predominantly using a door (71%) as the anchor point. Over-the-door alarms were a suggested intervention that stemmed from RCAs.…”

Section: Suicides (N = 3)mentioning

confidence: 95%

“…Over-the-door alarms were a suggested intervention that stemmed from RCAs. Mills et al 32 studied the impact of over-the-door alarms on suicides, which were implemented by certain VA psychiatric units between 2008 and 2019. Measures of intervention effectiveness were reported as both as adverse events (count of suicides) and root cause (count of suicide attempts and completed suicides using door as an anchor point) in psychiatric units with and without over-the-door alarms.…”

Section: Suicides (N = 3)mentioning

confidence: 99%

“…The majority of studies did not undertake measures to address and categorize nonresponders (ie, unreported adverse events), raising concerns about nonresponse bias. 26,29,[31][32][33][34][35][36] Ethical review board approval was obtained in 5 studies, 26,27,29,32,35 and was not explicitly stated in the other 5 studies. 30,31,[33][34][35] The interrater reliability of the 2 reviewers was between 80% and 100% for each study.…”

Section: Risk Of Bias Within Studiesmentioning

confidence: 99%

“…While the randomized control trial is the "gold standard" to prove causation between an intervention and an improvement in patient safety, it is neither feasible nor ethically appropriate to withhold patient safety interventions in a real-world setting. Five of the studies provided descriptive statistics, [32][33][34][35][36] while the remaining studies used inferential statistics to estimate the association between interventions and adverse event outcome measures. 26,27,[29][30][31] Statistical differences and significance in adverse event rates pre-and post-implementation help demonstrate the effectiveness of RCAs.…”

mentioning

confidence: 99%

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Does Root Cause Analysis Improve Patient Safety? A Systematic Review at the Department of Veterans Affairs

Shah

Falconer

Cimiotti

2022

Quality Management in Health Care

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Background and Objectives: While root cause analysis (RCA) is used to analyze medical errors with a systems approach, evidence demonstrating its effectiveness in reducing patient harm remains sparse. The heterogeneity of the RCA methodology at different health care organizations has posed challenges to studying its value. The Department of Veterans Affairs (VA) has an established and standardized RCA approach, making it an ideal context to study RCA's impact. This review assessed whether implemented interventions recommended by RCAs were effective in mitigating preventable adverse events at the VA. Methods: PubMed, Web of Science, CINAHL and Business Source were searched for studies on RCAs performed at the VA that evaluated effectiveness of interventions and were published between 2010 and 2020. The Appraisal Tool for Cross-sectional Studies (AXIS) was used to assess bias of bias. Results: The majority of studies eliminated during our eligibility process reported on RCAs without attention to their specific impact on patient safety. Ten retrospective studies met inclusion criteria and were part of the final review. Studies were grouped into adverse events related to incorrect surgical/invasive procedures, suicides, falls with injury, and all-cause adverse events. Six studies reported on effectiveness by demonstrating quantitative changes in adverse events over time or by location following a specific intervention. Four studies reported on the effectiveness of implemented interventions using a facility-based rating of “much better” or “better.” Conclusions: Of the studies included in this review, all reported improvements following interventions implemented after RCAs, but with variability in study definitions and methodology to assess effectiveness. Increased reporting of outcomes following RCAs, with an emphasis on quantitative patient-related outcome measures, is needed to demonstrate the impact and value of the RCA.

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Section: Suicides (N = 3)mentioning

confidence: 95%

Section: Suicides (N = 3)mentioning

confidence: 99%

Section: Risk Of Bias Within Studiesmentioning

confidence: 99%

mentioning

confidence: 99%

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Does Root Cause Analysis Improve Patient Safety? A Systematic Review at the Department of Veterans Affairs

Shah

Falconer

Cimiotti

2022

Quality Management in Health Care

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“…Barrera et al (2020) in their qualitative study on the utilization of MDT, also reported advantages for staff, including a perceived reduction in physical and verbal aggression and an improvement in the experience of providing care at night. Furthermore, Mills et al (2020) also evidenced advantages for staff using OTD. The authors acknowledged that the device provided the benefit of alerting workers if a patient attempted to hang himself from an ODTequipped door.…”

Section: Benefit To Staffmentioning

confidence: 93%

Utilization and effects of security technologies in mental health: A scoping review

Anastasi

Bambi

2023

Int J Mental Health Nurs

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Violence in healthcare is an urgent and increasing issue. Mental health settings are particularly affected, with severe negative impacts on staff, patients, and organizations. Security technologies could help maintain and improve safety in this field. However, knowledge of their utilization and effectiveness in mental health is lacking. A scoping review was conducted using the methodology recommended by the Joanna Briggs Institute to map research on the utilization and effects of security technologies in mental health, identify how research is currently performed, and highlight gaps in the existing knowledge. Literature search for peer‐reviewed publications was performed on PubMed, CINAHL, PsycInfo, Embase, and Scopus. Following the screening process and the eligibility criteria, 22 articles were included in this review. The publication range was 2002–2020, many studies were surveys, and European countries were the most investigated, especially the United Kingdom. Overall, the use of 10 different technologies was reported 46 times. The most represented category was alarms, followed by video cameras, other technologies (such as wearable sensors), and metal detectors. More than half of the included papers reported positive effects of these measures on safety. This review indicates that several security technologies are available in mental health settings, with encouraging positive safety outcomes for both patients and healthcare professionals, especially nurses. However, research on the topic is still emerging, with a limited number of sources and a few high‐quality designed studies. Therefore, future research should focus on producing evidence on the availability and effectiveness of these measures in mental health settings across countries.

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A Review of Modifiable Health Care Factors Contributing to Inpatient Suicide: An Analysis of Coroners’ Reports Using the Human Factors Analysis and Classification System for Healthcare

Sweeting,

Finlayson,

Hartz

2024

The Joint Commission Journal on Quality and Patient Safety

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Impact of over-the-door alarms: Root cause analysis review of suicide attempts and deaths on veterans health administration mental health units

Cited by 4 publications

References 6 publications

Does Root Cause Analysis Improve Patient Safety? A Systematic Review at the Department of Veterans Affairs

Does Root Cause Analysis Improve Patient Safety? A Systematic Review at the Department of Veterans Affairs

Utilization and effects of security technologies in mental health: A scoping review

A Review of Modifiable Health Care Factors Contributing to Inpatient Suicide: An Analysis of Coroners’ Reports Using the Human Factors Analysis and Classification System for Healthcare

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