Safety of Psychiatric Inpatients at the Veterans Health Administration

Marcus, Steven C.; Hermann, Richard C.; Frankel, Martin R.; Cullen, Sara

doi:10.1176/appi.ps.201700224

Cited by 27 publications

(36 citation statements)

References 39 publications

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“…This equates to approximately 8% of the patients treated in the hospital. This level of AEs is consistent with some studies 23,27 while a more recent study reported approximately 20% patients experienced a patient safety event 28,37 .…”

Section: Statement Of the Principal Findingssupporting

confidence: 91%

“…In Marcus`s survey 37 the most frequent events were medication errors (delayed and missed doses, 17.2%), followed by adverse drug events (4.1%), falls (2.8%), and assaults (1.0%). Most reported patient safety events (94.9%) resulted in little or no harm although more than half of the events (56.6%) were deemed preventable 37 .…”

Section: Statement Of the Principal Findingsmentioning

confidence: 99%

“…This means that there are no other studies to directly compare our results with. Nevertheless, there are some studies that have focused on AEs or patient safety events in psychiatric care but these accounts provide little agreement on what constitutes an AE in a psychiatric environment 18,24 and most studies have focused on the frequency of specific AE such as suicide 33,41 , assaults 42 , violence 43 , medication errors 21,[44][45][46] or falls 18,37 .…”

Section: Statement Of the Principal Findingsmentioning

confidence: 99%

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Mitigating risk in Norwegian psychiatric care: Identifying triggers of adverse events through Global Trigger Tool for psychiatric care

Okkenhaug

Tritter

Myklebust³

et al. 2019

JRS

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BACKGROUND: Patients treated in psychiatric care are exposed to the risk of adverse events, similar to patients treated in somatic health care. OBJECTIVES:In this article we report the findings of triggers associated with adverse events (AEs) identified by a version of GTT-P (Global Trigger Tool -Psychiatry) adapted for Norwegian hospital-based psychiatric treatment. METHODS:The design was a retrospective analysis of a random sample of 240 patient records from a psychiatric clinic in one Norwegian hospital. Patient records were sampled from both inpatient and outpatient psychiatric clinics in hospitals serving the northern part of the county of Trøndelag, Norway. RESULTS:Our analysis was based on the identification of 32 potential triggers of adverse events. Eighteen of the triggers were significantly related to adverse events.No adverse events were identified in patient records that did not also contain triggers included in the Global Trigger Tool. CONCLUSIONS:There is a clear relationship between the presence of triggers in a patient record and the likelihood of adverse events. Particularly relevant for psychiatric patients is 'suffering' as a trigger and this may also be relevant to somatic care and has implications for inclusion in the GTT-P.

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Section: Statement Of the Principal Findingssupporting

confidence: 91%

Section: Statement Of the Principal Findingsmentioning

confidence: 99%

Section: Statement Of the Principal Findingsmentioning

confidence: 99%

See 1 more Smart Citation

Mitigating risk in Norwegian psychiatric care: Identifying triggers of adverse events through Global Trigger Tool for psychiatric care

Okkenhaug

Tritter

Myklebust³

et al. 2019

JRS

View full text Add to dashboard Cite

show abstract

“…In 7 studies, no factors were identified [31,34,50,58,65,78,81] and in two, it was unclear [44]. Most studies reporting factors, discussed multiple individual factors (range = 1-7, average = 2.3) across multiple domains (range = 1-4, average = 2.0).…”

Section: Description Of Contributory/associated Factorsmentioning

confidence: 99%

Patient safety in marginalised groups: a narrative scoping review

Cheraghi-Sohi

Panagioti

Daker‐White

et al. 2020

Int J Equity Health

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Background: Marginalised groups ('populations outside of mainstream society') experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising.Methods: Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day.Results: The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors.Conclusions: This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks.Trial registration: Not applicable for a scoping review.

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“…A previous safety study reported that severely mentally ill patients admitted to medical-surgical wards experienced a mean number of almost six AEs per hospitalization (Daumit et al, 2016). A first study into safety of hospitalized psychiatric patients reported that approximately one in five patients experienced a patient safety event (AEs or medical errors) (Marcus, Hermann, Frankel, & Cullen, 2017). To our knowledge, a study evaluating process and outcome indicators of psychiatric inpatient care for patients with psychosis is lacking.…”

Section: Introductionmentioning

confidence: 99%

Measuring process indicators and adverse events to assess the quality of care for inpatients with psychosis

Vermeulen

Rooijen

Tricht

et al. 2019

Journal of Mental Health

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Background: Research into the quality of care in psychiatry is scarce. Data collection is falling behind that for other fields of medicine and therefore the opportunity to improve care is missed. Aims: In this medical record study we aim to determine: (i) whether or not patients' physical health indicators are assessed and pharmacological and behavioural treatment interventions applied; (ii) the incidence and nature of adverse events in psychotic inpatients. Methods: Medical records of inpatients with psychosis admitted to psychiatric wards at Amsterdam UMC, location AMC, Department of psychiatry, were screened with a previously developed and tested two-step patient safety tool. Results: Data of 299 admissions were included. Physical health indicators were not assessed in onethird of cases. Fifty-five percent of the patients were smokers but only 1% received an intervention. The family was actively involved in 43% of the cases. During 11,403 admission days, 235 adverse events had been recorded. The most frequent adverse event was adverse drug reactions (40%), which were mostly related to antipsychotic medication. Conclusions: In conclusion, quality of care auditing is useful to prioritize areas that need improvement. Future research should focus on interventions to improve the quality of psychiatric care.

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Safety of Psychiatric Inpatients at the Veterans Health Administration

Cited by 27 publications

References 39 publications

Mitigating risk in Norwegian psychiatric care: Identifying triggers of adverse events through Global Trigger Tool for psychiatric care

Mitigating risk in Norwegian psychiatric care: Identifying triggers of adverse events through Global Trigger Tool for psychiatric care

Patient safety in marginalised groups: a narrative scoping review

Measuring process indicators and adverse events to assess the quality of care for inpatients with psychosis

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