Adverse events in veterans affairs inpatient psychiatric units: Staff perspectives on contributing and protective factors

Abstract

Objectives This study sought to identify risk factors and protective factors in hospital-based mental health settings in the Veterans Health Administration (VHA), with the goal of informing interventions to improve care of persons with serious mental illness. Methods Twenty key informants from a stratified sample of 7 VHA inpatient psychiatric units were interviewed to gain their insights on causes of patient safety events and the factors that constrain or facilitate patient safety efforts. Results Respondents identified threats to patient safety at the system-, provider-, and patient-levels. Protective factors that, when in place, made patient safety events less likely to occur included: promoting a culture of safety; advocating for patient-centeredness; and engaging administrators and organizational leadership to champion these changes. Conclusions Findings highlight the impact of systems-level policies and procedures on safety in inpatient mental health care. Engaging all stakeholders, including patients, in patient safety efforts and establishing a culture of safety will help improve the quality of inpatient psychiatric care. Successful implementation of changes require the knowledge of local experts most closely involved in patient care, as well as support and buy-in from organizational leadership.

Safety culture: perception of health professionals in a mental hospital

“…Similarly, a study conducted in the United States highlighted the importance of promoting a culture of safety in these scenarios, something that can only occur with the involvement of patients, their family and management, since the mental health environment has specific needs that need to be recognized by the latter (18) .…”

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

“…Implementation of PSC improves clinical practices; for example, the introduction of PSC has been linked to reductions in adverse events/errors (El‐Jardali, Dimassi, Jamal, Jaafar, & Hemadeh, ; Mardon, Khanna, Sorra, Dyer, & Famolaro, ; Robb & Seddon, ; Singer et al, ; Wang et al, ) and an improvement in certain clinician behaviours such as error reporting (Verbakel, Langelaan, Verheij, Wagner, & Zwart, ). In psychiatric care, culture has been identified as a critical patient safety factor (Kanerva, Lammintakanen, & Kivinen, ; True, Frasso, Cullen, Hermann, & Marcus, ; Vandewalle et al, ). Systematic reviews have found that healthcare organisations looking to improve PSC apply various strategies that directly involve the managers, including team‐based training programs, executive walk rounds, educational activities or training programs (Morello et al, ; Weaver et al, ).…”

“…To the best of our knowledge, only a limited number of studies have examined the role of PSC in a psychiatric setting (Dewa et al, 2018;Hamaideh, 2017;Vlayen, Hellings, Claes, Abdou, & Schrooten, 2015). Previous studies on patient safety in psychiatric care have focused on, for example, incidents/errors or adverse events such as medical errors, violent patient situations, and physical restraint or seclusion (Brickell et al, 2009;Hanrahan, Kumar, & Aiken, 2010;Jeffs, Rose, Macrae, Maione, & Macmillan, 2012;True et al, 2017). Despite critique concerning how effective a patient safety incident reporting system (PSiRS) is at improving patient safety (Mitchell, Schuster, Smith, Pronovost, & Wu, 2016;Stavropoulou, Doherty, & Tosey, 2015), it is nevertheless important to evaluate which strategies for improving patient safety are effective in various contexts.…”

Patient safety in inpatient mental health settings: a systematic review

“…With regard to policy, eight studies concerned safety policies related to: observation,271 272 risk assessment,273 274 treatment,275 safeguarding,276 security277 and ergonomic improvement 278. Two papers focused on the role of patient and family engagement in safety,279 280 and two papers focused on how to build better therapeutic relationships to improve patient safety 281 282…”