__________________________________ Keeping Clients Safe: Error and Safety in Behavioral Health Settings
be allowed to pray in his room? Lee answers yes, and then receives a call that he is needed in another part of the hospital. On his way, Lee places a call to Amy, the social worker, and leaves a voicemail message, asking that she call him about Mr. Chey and requesting that she convene a family session the day after tomorrow, which is when he is next scheduled to work at the hospital. Jenn, a nurse, and Elise, a nursing assistant, are working the evening shift. They agree to share responsibility for monitoring Mr. Chey’s suicide watch and decide to check on him at five-minute intervals. With Mr. Chey’s admission, the unit is at full capacity, and he is given the only vacant room, at the far end of the corridor. Each time Jenn or Elise pass his open door, they find Mr. Chey kneeling at his bed, head bowed. And each time, he turns, acknowledges them with a nod and a smile, and turns back to pray. When Jenn returns to the nursing station after distributing the evening medications, she asks Elise when she last checked on Mr. Chey. Elise responds with a surprised look and says that she assumed that Jenn would be checking on him as she passed out medications. They race to Mr. Chey’s room together and find him hanging from a bedsheet attached to the back of the door. Mr. Chey’s suicide meets The Joint Commission’s criteria of a sen- tinel event (the suicide of any patient receiving care, treatment, and services in a staffed, around-the-clock care setting or within 72 hours of discharge), and a root cause analysis is scheduled five days after his death (The Joint Commission, 2022a). Two employees from the Quality Improvement Department, a facili- tator and a scribe, arrive at the unit conference room 15 minutes early to prepare for the session. They post large sheets of white paper around the room, labeling each sheet with a different heading: Physical Causes, Environment, Human Factors, Communication, Staffing, and Policies. These particular labels emerged from findings in root cause analyses conducted in other parts of the hospital; the categories are flexible and can be refined as needed. This is the first time that a root cause analysis will be conducted on the psychiatric unit, and the facilitator and scribe wonder if the categories will be applicable in a behavioral setting. As the facilitator watches the participants settle in the conference room—Jenn (nurse) and Elise (nursing assistant), Lee (interpreter), Amy (social worker), Dr. Gordon (psychiatric resident), and Terry (head nurse)—she notices that everyone seems nervous. After introduc- tions, the facilitator asks if anyone has participated in a root cause analysis process before, and all the participants shake their heads no. Jenn, the nurse, however, has heard about the process from another nurse who works in neurosurgery, and her friend reported that the experience had been positive. The facilitator explains that root cause analysis is a process designed to uncover flaws in the system. Despite the system focus, she cautions the participants that they will likely feel an urge to blame, and that this is a natural human tendency whenever a tragedy occurs. She goes on, saying that in guiding the root cause analysis session, if she hears any attempt to place blame, it is her responsibility to redirect the conversation, moving it back to a focus on the system.
• Determine improvements in processes and systems that might decrease the likelihood of such events in the future, or after analysis, determine that no such improvement opportunities exist • Include participation by the organization’s leadership as well as those involved in the processes and systems under review • Be internally consistent (i.e., be conducted the same way every time, not contradict itself or leave obvious questions unanswered) • Be informed by relevant literature and research • Include corrective outcome measures and top management approval Self-Assessment Question 2. The director of patient safety for a group of more than 50 inpatient psychiatric hospitals, each facility serving varying populations, geriatric, adults, adolescents, and children, hires a consulting firm to propose a company-wide new process involving an RCA of adverse events. How might this approach be ineffective? A) Failure to learn specific circumstances at each hospital could make the effort too generic. B) The program might be too expensive, disrupting hospital budgets. C) Staff may be too busy to attend training and study new process manuals. D) If the training occurs near the holidays, staff may be on vacation. CASE STUDY 2 The following case demonstrates a root cause analysis that was conducted following a sentinel event, and it meets The Joint Commission’s criteria. Khemrin Chey is a 60-year-old widower who emigrated from Cambo- dia through a church-sponsored program. A former teacher, Mr. Chey lives with his married daughter and works as a janitor for the church. This afternoon, the pastor discovers Mr. Chey sobbing in the church basement and calls his daughter, who brings her father to the hospital emergency department. Lee, an interpreter who works at the hospital, assists Dr. Gordon, the psychiatric resident, as he evaluates Mr. Chey for admission. Mr. Chey’s daughter provides recent history, reporting that her father has refused to eat for the past two weeks and has slept less than three hours a night during this time. Since his arrival in the U.S., Mr. Chey has repeatedly told his daughter that he desires to join his deceased wife. At this point in the interview, Dr. Gordon is paged to another emergency. He admits Mr. Chey to the psychiatric unit with a provisional diagnosis of major depressive disorder, places him on periodic suicide watch, and promises to return that evening to complete his assessment. To eliminate any possibility of miscom- munication, Lee, the interpreter, explains all of this to both Mr. Chey and his daughter. In response, Mr. Chey asks one question: Will he
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