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Error Prevention

While empirical evidence in the inpatient psychiatric setting is more limited than in other areas of healthcare, progress has been made in our understanding of patient safety, how to mitigate threats and reduce the probability of errors. The threat of harm can be physical and psychological and arise from the complex interaction between the patient and the health care environment. Among the most common threats of harm are medication errors, falls, and threats unique to psychiatric care, such as violence, aggression, and suicide.

Presented in this key element are studies and research to practice evidence that have been shown to mitigate errors that are common to our practice setting. Of equal importance, the research builds upon previous knowledge to offer greater clarity, further validate the continued use of patient safety strategies, or suggest the need to shift away from strategies that are not shown to be effective. Indeed, research shows that some commonly used hospital procedures increase the risk for physical and psychological harm, including the risk for aggression and suicide.

A successful patient safety program that mitigates errors must incorporate the other key components of a safe environment. For example, patient safety relies on adequate staffing, nurse engagement, training that teaches skills that prevent violence long before de-escalation is needed, and a milieu structure and culture that supports it. Therefore, additional references can be found in the other key components sections that are essential to error prevention and patient safety. Ideally, the key components would be designed, aligned, reviewed, and viewed as critical parts of one large process.

Abraham S (2016) Factors Contributing to Psychiatric Patient Falls. J Community MedHealth
6:410. doi:10.4172/2161-0711.1000410

“The purpose of this literature review was to identify studies and other literature about patient falls and to investigate the factors contributing to psychiatric inpatient falls. Studies on patient falls among psychiatric patients are scarce compared to research conducted on medical-surgical and community-dwelling patients. Falls related to the intrinsic, and extrinsic factors are identified, and potential interventions are discussed. It is evident from the review that falls incur financial burden and decreases the quality of life for the patient. Fall risk assessment tools have not been very helpful. The most common factors for fall risk are multiple medications, confusion, unsteady gait, and history of falls. Reduction in patient falls can be accomplished using a multifactorial assessment and team intervention.”

Delaney, K. R., Loucks, J., Ray, R., Blair, E., Nadler-Moodie, M., Batscha, C., Sharp, D., &
Milliken, D. (2020). Delineating Quality Indicators of Inpatient Psychiatric Hospitalization. Journal of the American Psychiatric Nurses Association, 1078390320971367. Advance online publication.

“Assuring quality care is critical to the well-being and recovery of individuals receiving inpatient psychiatric treatment, yet a comprehensive map of quality inpatient care does not exist. The participants’ responses compliment the quality literature and reinforce the need to develop a comprehensive map of quality elements. These elements interact in complex way, for instance, staffing, engagement, and teamwork is tied to the organizational structure and philosophy of care, which in turn facilitates consumer involvement in care. Thus, gauging the impact of quality on outcomes will demand consideration of the interaction of factors not just the linear relationship of one element to an outcome.”

Dickens, G. L., Tabvuma, T., & Frost, S. A. (2020). Safewards: Changes in conflict,
containment, and violence prevention climate during implementation. International Journal of Mental Health Nursing.

“Since its development, there has been growing utilization of the Safewards package of interventions to reduce conflict and containment in acute mental health wards. The current study used the opportunity of an implementation of Safewards across one large metropolitan local health district in New South Wales Australia to evaluate change. Specific aims of the study were to measure, for the first time in Australia, changes in shift-level reports of conflict and containment associated with Safewards introduction, and to measure any association with change in the violence prevention climate using a tool validated for use in the current study setting. Eight of eleven wards opted-in to participating in Safewards. Implementation was conducted over a period of 24 weeks (4-week preparation, 16-week implementation, and 4-week outcome phases). Conflict and containment were measured using the Patient–Staff Conflict Checklist Shift Report and violence prevention climate using the VPC-14. From 63.2% response rate, the mean (SD) reported conflict and containment incidents per shift fell from 3.96 (6.25) and 6.81 (5.78) to 2.94 (4.22) and 5.82 (4.62), respectively. Controlling for other variables, this represented reductions of 23.0 and 12.0%, respectively. Violence prevention climate ratings did not change. Safewards was associated with significant improvements in all incidents of conflict and containment, including the most severe and restrictive types, and this was largely unaffected by outcomes measure response rate, shift or weekday/weekend reporting, or number of ward beds. Safewards is increasingly justified as one of very few interventions of choice in adult, acute mental health services and should be widely utilized.”

Härkänen, M., Saano, S., & Vehviläinen, J. K. (2017). Using incident reports to inform the
prevention of medication administration errors. Journal of Clinical Nursing, 26(21–22), 3486–3499.

“Describe ways of preventing medication administration errors based on reporters’ views expressed in medication administration incident reports. Background: Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters’ perceptions of how to prevent medication administration errors have rarely been analyzed. Design and Methods: This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free‐text descriptions include reporters’ views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014. Results: Reporters’ views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organizations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organization were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work. Conclusions: Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication. Relevance to clinical practice: Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health professionals to manage daily medications should be prioritized.”

Herr, N. R., Jones, A. C., Cohn, D. M., & Weber, D. M. (2015). The impact of validation and
invalidation on aggression in individuals with emotion regulation difficulties. Personality Disorders: Theory, Research, and Treatment, 6(4), 310–314.

“For individuals with difficulty regulating their emotions, aggression has been found to be a particularly problematic interpersonal behavior. Invalidation (i.e., rejection of one’s emotional experience) is thought to play a role in the etiology of disorders of emotion regulation, and it may be a trigger for aggressive behaviors. The present study experimentally manipulated validation and invalidation after a sad mood induction among individuals with few versus many difficulties regulating their emotions. Subsequent aggression was measured using an in-laboratory behavioral task. Results indicate that, among individuals with many difficulties regulating their emotions, validation led to significantly less aggression than did invalidation. However, among individuals with few difficulties regulating their emotions, aggressive behaviors were generally low and did not differ after validation as compared with invalidation. The findings suggest that validation of emotional experiences may help to prevent aggressive behaviors among individuals with difficulties regulating their emotions.”

Keers, R. N., Plácido, M., Bennett, K., Clayton, K., Brown, P., & Ashcroft, D. M. (2018). What
causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PloS one, 13(10), e0206233.

“To our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific medication administration errors (MAEs) in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent ‘system’ failures, which emphasizes the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organizational ‘systems’ failures to reduce error.”

Malik, Angela MSN, RN; Patterson, Norma MSN, RN Step up to prevent falls in acute mental
health settings, Nursing: July 2012 – Volume 42 – Issue 7 – p 65-66 doi: 10.1097/01.NURSE.0000415322.94128.1f

“FALL PREVENTION is an ongoing challenge in older patients in the inpatient acute mental health setting. Fall prevention and patient safety committees should work together to minimize the risk. This article discusses why falls occur and how to prevent them in older adults with mental health problems in an inpatient setting. Incorporating fall prevention toolkits and evidence-based practices is vital.”

Marcus, S. C., Hermann, R. C., Frankel, M. R., & Cullen, S. W. (2018). Safety of Psychiatric
Inpatients at the Veterans Health Administration. Psychiatric services (Washington, D.C.), 69(2), 204–210.

“Although reducing adverse events and medical errors has become a central focus of the U.S. health care system over the past two decades both within and outside the Veterans Health Administration (VHA) hospital systems, patients treated in psychiatric units of acute care general hospitals have been excluded from major research in this field. Although patient safety events in VHA psychiatric inpatient units were relatively common, a great majority of these events resulted in little or no patient harm. Nevertheless, many were preventable, and the study provides data with which to target future initiatives that may improve the safety of this vulnerable patient population”.
Newbill, W. A., Marth, D., Coleman, J. C., Menditto, A. A., Carson, S. J., & Beck, N. C. (2010).
Direct observational coding of staff who are the victims of assault. Psychological Services, 7(3), 177–189.

“Staff members in psychiatric hospitals are frequently assaulted by patients. When asked what events triggered specific assaults on staff, staff and patients disagree. Staff members usually say that symptoms of psychosis led to the assault, whereas patients usually say aversive interactions with staff triggered the incident. For years, experts have called for direct observational research to address this issue and possibly resolve the discrepancy found in the verbal-report data. Over 26,000 hours of direct observational coding of staff activities, including staff–patient interactions, was collected across 10 years by independent, noninteractive raters on Social Learning Program units. Eight of nine kinds of aversive staff–patient interactions occurred more frequently among staff members who had been assaulted. One possible interpretation of these data is that aversive interactions lead to assaults on staff, but other possibilities must be considered. Practical recommendations for reducing likelihood of assault are detailed.”

Ocker, Stephanie Ann BSN, RN-BC; Barton, Sandra A. MS, RN-BC; Bollinger, Norma MSN,
RN; Leaver, Cynthia A. PhD, APRN, FNP-BC, FAANP; Harne-Britner, Sarah DNP, RN, ACNS-BC, NEA-BC; Heuston, Melanie M. DNP, RN, NEA-BC Preventing Falls Among Behavioral Health Patients, AJN, American Journal of Nursing: July 2020 – Volume 120 – Issue 7 – p 61-68 doi: 10.1097/01.NAJ.0000688256.96880.a3

“How an interprofessional team redesigned a fall prevention program to reduce the rate of fall-related injuries on an adult inpatient behavioral health unit. An interprofessional team approach using evidence-based practice and root cause analysis is effective in redesigning and implementing a fall prevention program for the adult inpatient behavioral health population.”

Polacek, M. J., Allen, D. E., Damin-Moss, R. S., Schwartz, A. J., Sharp, D., Shattell, M.,
Souther, J., & Delaney, K. R. (2015). Engagement as an Element of Safe Inpatient Psychiatric Environments. Journal of the American Psychiatric Nurses Association, 21(3), 181–190.

“The American Psychiatric Nurses Association (APNA) Institute for Safe Environments (ISE) has focused on key elements that affect safety in psychiatric treatment environments; one of these key elements is patient engagement. An ISE workgroup discussed and reviewed the literature on engagement and safety in inpatient psychiatric settings. This article presents what we have learned about the role that engagement plays in inpatient treatment of severely mentally ill individuals and evidence that links nurse-patient engagement to safety.”

Slemon, A., Jenkins, E., & Bungay, V. (2017). Safety in psychiatric inpatient care: The impact of
risk management culture on mental health nursing practice. Nursing inquiry, 24(4), e12199.

“The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self-harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re-center meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re-evaluating the risk management culture that gives rise to and legitimizes harmful practices.”

Substance Abuse and Mental Health Services Administration. SAMHSA™s Concept of Trauma
and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884 . Rockville : SAMHSA ; 2014 . Available at:

“Hospital procedures that place patients at risk for re-traumatization include removal of clothing, placing patients in vulnerable positions, power differentials between the patient and staff, and loss of and lack of privacy.”

Thibaut, B., Dewa, L. H., Ramtale, S. C., D’Lima, D., Adam, S., Ashrafian, H., Darzi, A., &
Archer, S. (2019). Patient safety in inpatient mental health settings: a systematic review. BMJ open, 9(12), e030230.

“This review informs academics, clinicians and service providers about the evidence base in the patient safety field within inpatient mental health settings. The findings allow researchers and clinicians to be directed to literature relevant to a given patient safety topic area, a useful starting point when developing practice guidelines 295. Similarly, the findings may influence clinical practice, with those implementing interventions or designing service changes being able to easily access the current scientific understanding.”

Torres, W. J., & Bergner, R. M. (2012). Severe public humiliation: Its nature, consequences, and
clinical treatment. Psychotherapy, 49(4), 492–501.

“In this article, we present an analysis of what is involved when our clients undergo severe public humiliation at the hands of another person or persons. We describe (a) the structure of such humiliation; that is, the factors that, taken collectively, render certain interpersonal events and circumstances humiliating ones for people; (b) the most common damaging consequences of being subjected to these, up to and including suicide and homicide; and (c) a number of therapeutic interventions that have proven effective in our own work with humiliated clients, as well as certain obstacles we have encountered in this work.”

Vermeulen, J. M., Doedens, P., Cullen, S. W., van Tricht, M. J., Hermann, R., Frankel, M., de
Haan, L., & Marcus, S. C. (2018). Predictors of adverse events and medical errors among adult inpatients of psychiatric units of acute care general hospitals. Psychiatric Services, 69(10), 1087–1094.

“The aim of this study was to identify factors associated with the occurrence of adverse events (AEs) or medical errors (MEs) during inpatient psychiatric hospitalizations. Methods: A full-probability random sample of 4,371 charts from 14 inpatient psychiatric units at acute care general hospitals in Pennsylvania were reviewed in a two-stage process that comprised screening and flagging by nurses followed by review by psychiatrists. AE and ME rates were calculated overall and then stratified by patient and hospital factors. Unadjusted and adjusted logistic regression models examined predictors of AEs and MEs. Results: An AE was identified in 14.5% of hospitalizations (95% confidence interval [CI] = 11.7–17.9), and an ME was identified in 9.0% (CI = 7.5–11.0). In adjusted analyses, patients with a longer length of stay and older patients had higher odds of experiencing an AE or an ME. Patients ages 31–42 (compared with ages 18–30), with commercial insurance (compared with Medicare or Medicaid or uninsured), or treated at high-volume hospitals (compared with low, medium, or very high) had lower odds of an AE. Patients age 54 or older (compared with ages 18–30), admitted during the weekend, admitted to rural hospitals (compared with urban), or treated at very-high-volume hospitals (compared with high) were more likely to experience an ME. Conclusions: This study provides insight into factors that put patients and hospitals at increased risk of patient safety events. This information can be used to tailor improvement strategies that enhance the safety of patients treated on general hospital psychiatric units.”