Riblet Natalie, Shiner Brian, Watts Bradley V, Mills Peter, Rusch Brett, Hemphill Robin R
*Veterans Affairs Medical Center, White River Junction, Vermont; †The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon; ‡Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and §Veterans Affairs National Center for Patient Safety, Ann Arbor, Michigan.
J Nerv Ment Dis. 2017 Jun;205(6):436-442. doi: 10.1097/NMD.0000000000000687.
There is a high risk for death by suicide after discharge from an inpatient mental health unit. To better understand system and organizational factors associated with postdischarge suicide, we reviewed root cause analysis reports of suicide within 7 days of discharge from across all Veterans Health Administration inpatient mental health units between 2002 and 2015. There were 141 reports of suicide within 7 days of discharge, and a large proportion (43.3%, n = 61) followed an unplanned discharge. Root causes fell into three major themes including challenges for clinicians and patients after the established process of care, awareness and communication of suicide risk, and flaws in the established process of care. Flaws in the design and execution of processes of care as well as deficits in communication may contribute to postdischarge suicide. Inpatient teams should be aware of the potentially heightened risk for suicide among patients with unplanned discharges.
从住院精神科病房出院后，自杀死亡风险很高。为了更好地理解与出院后自杀相关的系统和组织因素，我们回顾了2002年至2015年间所有退伍军人健康管理局住院精神科病房出院后7天内自杀的根本原因分析报告。有141份出院后7天内自杀的报告，其中很大一部分（43.3%，n = 61）是在计划外出院后发生的。根本原因分为三大主题，包括既定护理流程后临床医生和患者面临的挑战、自杀风险的认知和沟通，以及既定护理流程中的缺陷。护理流程设计和执行中的缺陷以及沟通不足可能导致出院后自杀。住院团队应意识到计划外出院患者中自杀风险可能会升高。
