Janofsky Jeffrey S
University of Maryland School of Medicine, USA.
J Am Acad Psychiatry Law. 2009;37(1):15-24.
In 1995, the Joint Commission began requiring that hospitals report reviewable sentinel events as a condition of maintaining accreditation. Since then, inpatient suicide has been the second most common sentinel event reported to the Joint Commission. The Joint Commission emphasizes the need for around-the-clock observation for inpatients assessed as at high risk for suicide. However, there is sparse literature on the observation of psychiatric patients and no systematic studies or recommendations for best practices. Medical errors can best be reduced by focusing on systems improvements rather than individual provider mistakes. The author describes how failure modes and effects analysis (FMEA) was used proactively by an inpatient psychiatric treatment team to improve psychiatric observation practices by identifying and correcting potential observation process failures. Collection and implementation of observation risk reduction strategies across health care systems is needed to identify best practices and to reduce inpatient suicides.
1995年，联合委员会开始要求医院报告可审查的警讯事件，作为维持认证的条件。从那时起，住院患者自杀一直是向联合委员会报告的第二常见警讯事件。联合委员会强调，对于被评估为有高自杀风险的住院患者，需要进行全天候观察。然而，关于精神科患者观察的文献稀少，也没有关于最佳实践的系统研究或建议。通过关注系统改进而非个别医护人员的失误，能最大程度减少医疗差错。作者描述了一个住院精神科治疗团队如何通过识别和纠正潜在的观察过程失误，积极主动地运用失效模式与效应分析（FMEA）来改进精神科观察实践。需要在整个医疗系统中收集并实施观察风险降低策略，以确定最佳实践并减少住院患者自杀事件。
