Keeping Clients Safe: Error and Safety in Behavioral Health Settings _ ________________________________
• Staffing: The psychiatric unit employed one registered nurse, one nursing assistant, and one social worker who covered 25 patients and their families. Lee (interpreter) worked two days a week, Wednesdays and Fridays. • Policies: The policy for assessment and treatment of suicidal patients did not address bedsheets or towels, room assignment, monitoring, or structured assessment of suicidal intent. At the conclusion of the root cause analysis, the staff discussed some initial ideas for a follow-up action plan, assigning specific responsibili- ties to individuals. • A structured suicide assessment would be administered to all patients immediately upon admission. Dr. Gordon (psychiatric resident) agreed to examine the literature to find a state-of-the-art instrument and discuss which instrument was best with the director of the residency program. Dr. Gordon promised to share his findings with the group within a week. • Suicidal patients would be assigned rooms across from the nurses’ station; access to bedclothes and towels would be restricted; a single individual would have responsibility for monitoring a suicide watch. Terry (head nurse) assumed responsibility for developing these policies and agreed to share them with the group within 10 days. • Lee (interpreter) suggested that interpreters be on call on an as-needed basis, rather than working assigned days. He also offered to present an in-service training to staff on Cambodian culture. Participants welcomed the offer of an in-service training. Terry (head nurse) agreed to discuss the possibility of interpreters being on call with the hospital’s vice president of clinical services and agreed to report her findings to the group at their next as-yet-to-be-scheduled meeting. • Participants agreed that additional staffing was unlikely, given the most recent round of budget cuts. The participants agreed to meet again in two weeks and then on a monthly basis to evaluate the effectiveness of the action plan, making changes as needed. Case Study 2 Discussion Given the complexities of this case, root cause analysis is an important tool; however, it is only a beginning step on the journey to a culture of safety. Root cause analysis, like traditional efforts to detect adverse events (such as incident reporting systems), relies on voluntary reporting. While the idea of a blameless, voluntary reporting system is beyond the scope of this course, it is worth mentioning because it sup- ports organizational learning, and learning is key to a culture of safety (Peerally et al., 2017). Supporting the providers in this case, Jenn and Elise, while helping to educate them about safer practices on the unit is a balancing act. Employees from the Quality Improvement Department need to walk a fine line, being mindful of accidently shaming the providers and
The facilitator continues, saying that, together, the participants will consider all possibilities to seek a root cause or causes. She will follow prompts suggested by The Joint Commission (The Joint Commission, 2022a), and for each finding that emerges, she will ask “Why?” and drill down to uncover the reasons that parts of the process did not happen when they should have. She will continue to dig deeper until no additional logical answers can be identified. The scribe will document the discussion by writing findings on the sheets on the wall. Participants will determine, with the facilitator’s guidance, which category is most appropriate for each finding; new categories will be added if needed. Another template is also displayed in the room as a visual aide (see Figure 2). The formal name for this template is an Ishikawa diagram, and it is also called a fishbone or cause-and-effect diagram. The labels on the template match the headings on the wall sheets, and after the session, the scribe will enter the information onto the cause-and-effect template in the order in which it was received from participants. When completed, the scribe will send a copy to each of the participants so that they can verify its accuracy. The facilitator prompts the discussion by asking what guidelines were in place regarding the assessment of suicidal patients at the time of Mr. Chey’s death. Dr. Gordon answers that the department of psychiatry’s policy is for residents to complete a psychiatric evaluation within six hours of admission. Since Mr. Chey’s death occurred within three hours of admission, the department’s guidelines were followed. The facilitator then asks about human factors (human performance factors that may have contributed to the event), environmental factors, staffing levels, communication, and the physical environment. The staff members discuss each of these factors, and the following information is written on wall sheets. • Physical causes (physical objects, including machinery and equipment): Although staff had removed Mr. Chey’s belt and shoes, the bedsheets remained in the patient’s room. • Environment (staffing, time of day, and acuity/census): Dr. Gordon was paged to the emergency department before he completed his assessment of Mr. Chey. The unit was at full capacity; Mr. Chey was assigned to a room that was far from the nurses’ station. There was only one registered nurse and one nursing assistant attending to the needs of 25 patients. The suicide occurred during the busiest time of day, when meals and medications were being distributed. • Human factors ( distraction, fatigue, failure to follow a specified protocol): Nursing staff members were distracted by other duties; there was no clear assignment of responsibility for individual monitoring (diffusion of responsibility); the psychiatrist did not administer a structured suicide assessment during the admission evaluation. • Communication: During the root cause analysis, Lee (interpreter) shared additional information that he had planned to discuss with Amy (social worker): (1) Mr. Chey was a proud man who had emigrated only because of pressure from his daughter and (2) nursing staff was pronouncing his name incorrectly.
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