Establishment of a Comprehensive Inpatient Suicide Prevention Network by Using Health Care Failure Mode and Effect Analysis

Changchien, Te-Chang; Yen, Yung-Chieh; Wang, Ying-Jhu; Chang, Yang-Chin; Ju, Reng-Sheng; Yen, Po-Feng; Cheng, Yu‐Ting; Shih, Mei-Ling; Huang, Y D

doi:10.1176/appi.ps.201700512

Cited by 6 publications

(9 citation statements)

References 6 publications

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“…We acknowledge that from a general point of view, some of our findings are similar to the conclusions drawn by our colleagues in the same field. Suicide risk is multifactorial, and decisions about appropriate safety measures are dependent on factors on both individual and structural levels 5 6 10 38 40 42 44 46 48 49 51 53–55 57 58 60–64 66 68–70. However, following the argumentation of Fried and Robinaugh (2021) on complexity, adverse events cannot be prevented by understanding the single components alone, neglecting the interactions among them 106.…”

Section: Discussionmentioning

confidence: 99%

“…Previous healthcare research on suicide prevention has focused mainly on single risk factors 38 39. Besides highlighting the importance of providing treatment to underlying illness, it stresses the reduction of accessibility to lethal means,40–45 combining immediate and long-term multilevel interventions,42 43 46 47 building trustful staff–patient relationships and involving relatives,48–50 conducting regular assessments in outpatient settings,49 51 52 designing safer environments for inpatients,53–56 following up earlier and maintaining closer supervision in the post-discharge period 57–66. To reduce organisational risk factors, better communication among professionals, proper education and provision of adequate guidelines have been suggested 15 49 52…”

Section: Introductionmentioning

confidence: 99%

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Coexisting service-related factors preceding suicide: a network analysis

et al. 2022

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ObjectivesThe overall objective was to analyse service-related factors involved in the complex processes that precede suicide in order to identify potential targets for intervention.Design and settingExplorative network analysis study of post-suicide root cause analysis data from Swedish primary and secondary healthcare.Participants217 suicide cases reported to the Swedish national root cause analysis database between 2012 and 2017.Primary and secondary outcome measuresA total of 961 reported incidents were included. Demographic data and frequencies of reported deficiencies were registered. Topology, centrality indices and communities were explored for three networks. All networks have been tested for robustness and accuracy.ResultsLack of follow-up, evaluations and insufficient documentation issues emerged as central in the network of major themes, as did the contributing factors representing organisational problems, failing procedures and miscommunication. When analysing the subthemes of deficiencies more closely, disrupted treatments and staffing issues emerged as prominent features. The network covering the subthemes of contributing factors also highlighted discontinuity, fragile work structures, inadequate routines, and lack of resources and relevant competence as potential triggers. However, as the correlation stability coefficients for this network were low, the results need further investigation. Four communities were detected covering nodes for follow-up, evaluation, cooperation, and procedures; communication, documentation and organisation; assessments of suicide risk and psychiatric status; and staffing, missed appointments and declined treatment.ConclusionThe results of this study suggest that healthcare providers may improve patient safety in suicide preventive pathways by taking active measures to provide regular follow-ups to patients with elevated suicide risk. In some cases, declined or cancelled appointments could be a warning sign. Tentative results show organisational instability, in terms of work structure, resources and staffing, as a potential target for intervention, although this must be more extensively explored in the future.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Coexisting service-related factors preceding suicide: a network analysis

et al. 2022

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“…Uma pontuação de risco é considerada para que a análise seja aprofundada da causa e assim propor estratégias de melhoria (Changchien et al, 2019).…”

Section: Ferramenta 2 -Análise Do Modo De Falha E Efeitos Na Assistên...unclassified

Ferramentas de gestão de risco na segurança do paciente suicida em emergências hospitalares

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Cabrera

et al. 2023

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Objetivos: Identificar ferramentas de gestão do risco na segurança do paciente com comportamentos suicidas, utilizadas nas emergências hospitalares. Metodologia: Revisão integrativa da literatura, no período de 2017 a 2021, a fim de responder à questão norteadora da pesquisa: Quais são as ferramentas de gestão utilizadas no gerenciamento do risco e da segurança do paciente em comportamentos suicidas no âmbito hospitalar? Utilizou-se a estratégia de busca PICO e a seleção dos estudos foi realizada por dois revisores de forma independente, no qual utilizaram como fontes de buscas as bases do Scopus, Web of Science e Pubmed. Resultados: Identificaram-se 863 artigos, dos quais 8 foram selecionados. Observou-se nos estudos que as ferramentas gerenciais foram: Protocolos de atendimento; Análise do Modo de Falha e Efeitos na Assistência Médica (HFMEA); Lista de Verificação (Check-list) e o Safety Huddle (reunião de segurança). Conclusões: As ferramentas de gestão do risco na segurança do paciente com comportamentos suicidas utilizadas em emergências hospitalares mostram resultados positivos com relação à prevenção ao suicídio nestes ambientes e que contribuem para uma assistência de qualidade e segura, porém carecem de mais evidências científicas.

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“…22,23 Similarly, the Health Care Failure Mode and Effective Analysis (HFMEA) can help establish a comprehensive inpatient suicide prevention network. 24 Once a patient is identified as a suicide risk, the process of transferring to the MH unit should be streamlined without prolonged waiting. This must include effective functioning of these facilities on all days, throughout the year, including weekends and holidays.…”

Section: Improving Detection and Awarenessmentioning

confidence: 99%

“…As of 2014, there were over 170,000 residents in inpatient and other 24-hour residential treatment beds on any given night, an average of over 53.6 patients per 100,000 population. In 2018, National Mental Health Services Survey (N-MHSS) estimated that the mean population rate for beds in mental hospitals in the United States, was 39.0 per 100,000, with a median of 31.4.…”

Section: Introductionmentioning

confidence: 99%

Inpatient suicide: epidemiology, risks, and evidence-based strategies

et al. 2022

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Suicide risk assessment is a continual process, and its utility primarily rests on 4 principles: therapeutic relationship, communication and collaboration, documentation of the assessment process, and cultural awareness, with special considerations for given care settings, life span, and traumatic life experiences. 15 Screening inpatients at a higher suicide risk relies on evaluating CNS Spectrums www.cambridge.org/cns

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Establishment of a Comprehensive Inpatient Suicide Prevention Network by Using Health Care Failure Mode and Effect Analysis

Cited by 6 publications

References 6 publications

Coexisting service-related factors preceding suicide: a network analysis

Coexisting service-related factors preceding suicide: a network analysis

Ferramentas de gestão de risco na segurança do paciente suicida em emergências hospitalares

Inpatient suicide: epidemiology, risks, and evidence-based strategies

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