media/tjc/documents/resources/patient-safety-topics/sentinel-event/sentinel-event-policy/ cambhc_21_se_all_current.pdf The Joint Commission. (2022b). Sentinel event data: General information & 2022 Q1, Q2 Update. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety- topics/sentinel-event/sentinel-event-general_information-june-2022.pdf The Joint Commission. (2023). Behavioral health care and human services: 2023 national patient safety goals. https://www.jointcommission.org/-/media/tjc/documents/standards/ national-patient-safety-goals/2023/npsg_chapter_bhc_jan2023.pdf Jung, S. J., Lee, Y., & Bae, S. H. (2022). Influence of clinical nurses’ second-victim experience and second-victim support in relation to patient safety incidents on their work-related outcomes. Journal of Korean Academy of Nursing Administration, 28(4), 331-341. https:// doi.org/10.11111/jkana.2022.28.4.331 Large, M., Myles, N., Myles, H., Corderoy, A., Weiser, M., Davidson, M., & Ryan, C. J. (2018). Suicide risk assessment among psychiatric inpatients: A systematic review and meta-analysis of high-risk categories. Psychological Medicine, 48(7), 1119-1127. Liu, D., Liu, X., & Wu, S. (2022, June). A Literature Review of Diffusion of Responsibility Phenomenon. In 2022 8th International Conference on Humanities and Social Science Research (ICHSSR 2022) (pp. 1806-1810). Atlantis Press. Luva, B., & Naweed, A. (2022). Authority gradients between team workers in the rail environment: A critical research gap. TheoreTical issues in ergonomics science, 23(2), 155- 181. Makary, M. A., & Daniel, M. (2016). Medical error: The third leading cause of death in the US. BMJ, 353. doi: 10.1136/bmj.i2139 Martínez-Alés, G., Jiang, T., Keyes, K. M., & Gradus, J. L. (2022). The recent rise of suicide mortality in the United States. Annual Review of Public Health, 43, 99-116. Mills, P. D., Watts, B. V., Shiner, B., & Hemphill, R. R. (2018). Adverse events occurring on mental health units. General Hospital Psychiatry, 50, 63-68. https://doi-org.ezproxy.umgc. edu/10.1016/j.genhosppsych.2017.09.001 Montague, J., Crosswaite, K., Lamming, L., Cracknell, A., Lovatt, A., & Mohammed, M. A. (2019). Sustaining the commitment to patient safety huddles: Insights from eight acute hospital ward teams. British Journal of Nursing, 28(20), 1316-1324. Morrissey, J., & Higgins, A. (2018). “Attenuating anxieties”: A grounded theory study of mental health nurses’ responses to clients with suicidal behaviour. Journal of Clinical Nursing, 28(5-6), 947-958. Mueller, B. U., Neuspiel, D. R., Fisher, E. R. S., Franklin, W., Adirim, T., Bundy, D. G., Ferguson, L. E., Gleeson, S. P., Leu, M., Quinonez, R. A., Rinke, M. L., Shiffman, R. N., Saarel, E. V., Tieder, J. S., Yin, H. S., Phillips, S. C., Quinonez, R., Brown, J. M., Walsh, K. M., ... Hsu, B. (2019). Principles of pediatric patient safety: Reducing harm due to medical care. 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Lippincott Williams & Wilkins. Panagioti, M., Khan, K., Keers, R. N., Abuzour, A., Phipps, D., Kontopantelis, E., ... & Ashcroft, D. M. (2019). Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ, 366:l4185 doi:10.1136/ bmj.l4185 Rationale: From an HRO perspective, it would be a mistake to eliminate steps in a critical patient process, especially if the only objective is to save time for frontline staff members. Mistakes can certainly occur when necessary processes are overly simplified and should therefore be critically resisted and examined to determine how they affect the possibility of patient risk. 2. The correct answer is a. Rationale: From an RCA perspective, a critical element for success is the application of an RAC process to the exact context of a particular setting or practice. General RCA concepts might apply; however, specific factors will quickly need to be addressed in order for the new program to be effective. This customization allows for concepts to serve the precise needs of patients, providers, and leadership within a very specific healthcare environment.
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Patient safety in inpatient psychiatry: A remaining frontier for health policy. Health Affairs, 37(11), 1853-1861. Smith, A. F., & Plunkett, E. (2019), People, systems and safety: Resilience and excellence in healthcare practice. Anaesthesia, 74, 508-517. https://doi.org/10.1111/anae.14519 Svensson, J. (2022). Patient safety strategies in psychiatry and how they construct the notion of preventable harm: A scoping review. Journal of Patient Safety, 18(3), 245-252. Thibaut, B., Dewa, L. H., Ramtale, S. C., D'Lima, D., Adam, S., Ashrafian, H., ... & Archer, S. (2019). Patient safety in inpatient mental health settings: A systematic review. BMJ Open, 9(12), e030230. Truog, R. D., Browning, D. M., Johnson, J. A., & Gallagher, T. H. (2011). Talking with patients and families about medical error: A guide for education and practice. Johns Hopkins University Press. U.S. Department of Veterans Affairs. (2014). Root cause analysis. http://www.patientsafety. va.gov/professionals/onthejob/rca.asp Veazie, S., Peterson, K., & Bourne, D. (2019). Evidence brief: Implementation of high reliability organization principles. Department of Veterans Affairs. Vincent, C., & Amalberti, R. (2015). Safety in healthcare is a moving target. BMJ Quality & Safety, 24(9), 539-540. doi: 10.1136/bmjqs-2015-004403 Walby, F. A., Myhre, M. Ø., & Kildahl, A. T. (2018). Contact with mental health services prior to suicide: A systematic review and meta-analysis. Psychiatric Services, 69(7), 751-759. Watts, P. I., McDermott, D. S., Alinier, G., Charnetski, M., Ludlow, J., Horsley, E., ... & Nawathe, P. A. (2021). Healthcare simulation standards of best practice TM simulation design. Clinical Simulation in Nursing, 58, 14-21. Weiss, M., & Morrison, E. W. (2018). Speaking up and moving up: How voice can enhance employees’ social status. Journal of Organizational Behavior. doi: 10.1002/job.2262 Wright, M. I., Polivka, B., Odom-Forren, J., & Christian, B. J. (2021). Normalization of Deviance: Concept Analysis. Advances in Nursing Science, 44(2), 171-180. Young, R. S., Deslandes, P., Cooper, J., Williams, H., Kenkre, J., & Carson-Stevens, A. (2020). A mixed methods analysis of lithium-related patient safety incidents in primary care. Therapeutic Advances in Drug Safety, 11. doi: 10.1177/2042098620922748 3. The correct answer is b. Rationale: From a speaking-up perspective, Janet’s best course of action is to speak up to Mark. If this is a pattern of oversight, or becomes a pattern of oversight, an adverse patient event is likely to occur. Janet is naturally anxious about speaking up to her supervisor because she is a new employee on the unit; however, she has a duty to the patients and the hospital to be responsible and work to keep all patients safe. 4. The correct answer is c. Rationale: This revelation of suicidal ideation and planning is critical. Ellen can act now to obtain authorization to speak with his wife and primary care provider, including them in creating a safer system of care for her new patient. Because the patient is new, it would be unwise to prematurely force him toward psychiatric admission—he might refuse, or potentially even more prematurely terminate with Ellen. Building rapport and creating a support team (his wife and primary care provider) establish the right clinical approach to keep her patient in therapy, which is the safest approach at this moment.
KEEPING CLIENTS SAFE: ERROR AND SAFETY IN BEHAVIORAL HEALTH SETTING Answer Keys & Rationales 1. The correct answer is b.
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