Predicting violent behavior in clinical settings: a case-control study of a mental health inpatient unit.

In order to assist staff in recognizing patients prone to violence and guide their clinical decision-making, this study summarizes mental health inpatient unit incidents over a one-year period. Results describe demographic and clinical information for patients, and evaluate risk assessment tools currently used to predict risk. A retrospective analysis included data on patients involved in incidents and frequency matched controls. There were a total of 44 incidents, caused by 38 unique patients. A constructed model to estimate patient characteristics and risk of violent incidents included involuntary admittance (OR 2.07, 95% CI 1.05-6.11, p = 0.039), more than one admission at the facility (OR 4.18, 95% CI 1.71-10.22, p = 0.002) and Global Subjective Irritability on day one (OR 4.24, 95% CI 1.77-10.16, p = 0.001). Violent incidents on the mental inpatient unit threaten safety and disrupt the therapeutic environment. The findings may be useful in aiding clinicians to quickly recognize patients that are prone to violence.

Suicide attempts and completions in Veterans Affairs nursing home care units and long-term care facilities: a review of root-cause analysis reports.

OBJECTIVE: Suicide was the 10th leading cause of death for Americans in 2010. The suicide rate is highest among men who are aged 75 and older. The prevalence of suicidal behavior in nursing homes and long-term care (LTC) facilities was estimated to be 1%. This study describes the systemic vulnerabilities found after suicidal behavior in LTC facilities as well as steps to decrease or mitigate the risk. METHOD: This is a retrospective review of root-cause analysis (RCA) reports of suicide attempts and completions between 1 January 2000 and 31 December 2013 in the Veterans Health Administration LTC and nursing home care units. The RCA reports of suicide attempts and completions were coded for patient demographics, method of attempt or completion, root causes, and actions developed to address the root cause. RESULTS: Thirty-five RCA reports were identified. The average age was 65 years, 11 had a previous suicide attempt, and the primary mental health diagnoses were depression, posttraumatic stress disorder, and schizophrenia. The primary methods of self-harm were cutting with a sharp object, overdose, and strangulation. CONCLUSIONS: It is recommended that all staff members are aware of the signs and risk factors for depression and suicide in this population and should systematically assess and treat mental disorders. In addition, LTC facilities should have a standard protocol for evaluating the environment for suicide hazards and use interdisciplinary teams to promote good communication about risk factors identified among patients. Finally, staff should go beyond staff education and policy to make clinical changes at the bedside. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Suicide attempts and completions on medical-surgical and intensive care units.

Studies of inpatient suicide attempts and completions on medical-surgical and intensive care units are rare, and there are no large studies in the United States. We reviewed 50 cases, including 45 suicide attempts and 5 completed suicides, that occurred on medical surgical or intensive care units in the Veterans Health Administration between December 1, 1999 and December 31, 2012. The method, location, and the root causes of the events were categorized. The most common methods included cutting with a sharp object, followed by overdose and hanging. Root causes included problems with communication of risk, need for staff education in suicide assessment, and the need for better treatment for depressed and suicidal patients on medical units. Based on these results, we made our recommendations for managing suicidal patients on medical-surgical and intensive care units, including improved education for staff, standardized communication about suicide risk, and clear management protocols for suicidal patients.

A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers.

BACKGROUND: Empirical evidence is limited that root cause analysis (RCA), an event analysis tool used in health care to evaluate the systemic factors that lead to adverse events, improves patient safety. A cross-sectional study was conducted to examine the relationship between RCA and patient safety. METHODS: RCA data were collected for the 139 Department of Veteran Affairs medical centers (VAMCs) in the National Center for Patient Safety database from 2004 through 2006. Participants were divided into three RCA utilization categories on the basis of their yearly RCA rate: (1) fewer than 4 RCAs, (2) 4 to 5 RCAs, and (3) 6 or more RCAs per year. An analysis of variance was conducted of each Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) across the three RCA utilization categories. RESULTS: Facilities completed between 3 and 59 RCAs in the three-year period (mean RCA utilization rate, 4.86 RCAs per year). In this period, RCA actions by facility ranged from 9 to 323 (mean, 28 actions per year per facility). Mean patient-days of care, facility budget, surgical volume, and the number of strong improvement actions were significantly different across RCA utilization categories. The mean rates of PSI 9 (Postoperative Hemorrhage or Hematoma), PSI 10 (Postoperative Physiologic and Metabolic Derangements), and PSI 13 (Postoperative Sepsis) were significantly different across RCA utilization categories. CONCLUSIONS: Large, high-spending VAMCs conduct more RCAs per year than smaller, low-spending facilities. VAMCs that do more RCAs develop more corrective actions. VAMCs that complete fewer than four RCAs per year have higher rates of postoperative complications. It is unclear if RCAs are associated with a functional patient safety program or directly improve patient safety.

Suicide attempts and completions in the emergency department in Veterans Affairs Hospitals.

BACKGROUND: This is the first study of suicide attempts and completions in the emergency department (ED) in a large national medical system. METHODS: All root cause analysis (RCA) reports completed of suicides and suicide attempts that occurred in ED in the Veterans Health Administration between 1 December 1999 and 31 December 2009 were reviewed. The method, location, anchor point for hanging and implement for cutting as well as the root causes were categorised. RESULTS: Ten per cent of all RCA reports of suicides and suicide attempts that occur within the hospital occur in the ED. Hanging, cutting and strangulation were the most common methods. The most common anchor point for hanging was doors, and the most common implement for cutting was a razor blade. In eight of the 10 cases of cutting, the implement was brought into the ED. The most common root causes were problems communicating risk and being short-staffed. CONCLUSIONS: Based on these results the following recommendations are made for helping to reduce suicide attempts in the ED: (1) use a systematic protocol and checklist to review mental health holding areas periodically in the ED for suicidal hazards; (2) develop and implement specialised protocols for suicidal patients that include continuous observation when possible; (3) conduct thorough contraband searches with suicidal patients; (4) designate specialised holding areas, when practically possible, for suicidal patients that are free of anchor points for hanging, sharps and medications, and medical equipment; and are isolated from exits to reduce the risk of elopement.

A checklist to identify inpatient suicide hazards in veterans affairs hospitals.

BACKGROUND: Approximately 1,500 suicides take place in inpatient hospital units in the United States each year. This study, the first of its kind, examines the implementation and effectiveness of using a standardized checklist for mental health units to improve patient safety in a large health care system. METHODS: In 2006 a Department of Veterans Affairs (VA) committee was charged with developing a checklist to explicitly identify environmental hazards on acute mental health units treating suicidal patients. The committee developed both general guidelines to be applied to all areas of the psychiatric unit and detailed guidelines for specific rooms, such as bathrooms, bedrooms, and seclusion rooms. RESULTS: Some 113 VA facilities used the Mental Health Environment of Care Checklist to evaluate their mental health units, identifying and rating 7,642 hazards. At the end of the first year of the project, because of the checklist, 5,834 (76.3%) of these hazards had been abated by facilities; approximately 2% were identified as critical hazards, and another 27% were rated as serious. The most common hazard was anchor points for hanging, followed by material that could be used as a weapon against staff or other patients and problems keeping patients in the secured unit environment. Anchor points had the greatest risk-level classification, followed by suffocation risk and poison risk. High-risk locations included bedrooms and bathrooms. DISCUSSION: Anchor points represented almost 44% of the total number of identified hazards, and materials that could be used as weapons comprised nearly 14% of the total. It is critical to review the mental health environment of care with an eye for these potential weapons. The checklist and resulting mitigations of hazards represent steps toward the overall goal of preventing inpatient suicides.

The effectiveness of root cause analysis: what does the literature tell us?

BACKGROUND: Root cause analysis (RCA) is an analysis framework used in health care to determine the systemic causes and prevent recurrences of adverse events. It is required by The Joint Commission for reported events and by the Department of Veterans Affairs (VA) National Center for Patient Safety for qualifying events in VA medical centers. The evidence on RCA effectiveness in improving patient safety was reviewed. METHODS: MEDLINE, Academic Search Premier, and the Cochrane Database were searched from database inception to September 2007. RCA case studies and articles that directly addressed the RCA framework were reviewed. RESULTS: Discussion of RCA did not emerge in the literature until the late 1990s, and there have been no controlled trials that test the RCA framework. Twenty-three articles describe the RCA process, 38 articles present RCA case studies, and 12 articles analyze weaknesses of the RCA framework. Eleven of the case studies measure RCA effectiveness, 3 using clinical outcome measures and 8 using process measures. All 11 articles report improvement of safety following RCA. RCA participants report the difficulty in forming causal statements and in developing/implementing corrective actions. Criticisms of RCA include the uncontrolled study design and participant biases. DISCUSSION: Overall, the limited literature on RCA effectiveness provides anecdotal evidence that RCA improves safety. At the same time, it highlights the numerous theoretical problems with the analytical framework. Formal studies at the system level and cost-benefit analysis are needed to determine the effectiveness of RCA. Structured publication of case studies will support shared knowledge and will provide benchmarks for improvement. Enrichment of the RCA literature body will enable reproducibility of improvement work, optimization of analysis, and validation of the framework itself.