The Geisel School of Medicine, Dartmouth College, Hanover, NH, United States; VAMC, 215 N. Main Street, White River Junction, VT 05009, United States.
The Geisel School of Medicine, Dartmouth College, Hanover, NH, United States; VAMC, 215 N. Main Street, White River Junction, VT 05009, United States.
Gen Hosp Psychiatry. 2018 Jan-Feb;50:63-68. doi: 10.1016/j.genhosppsych.2017.09.001. Epub 2017 Sep 9.
While the study of suicide on mental health units has a long history, the study of patient safety more generally is relatively new. Our objective was to determine the type and relative frequency of adverse events occurring on Veterans Health Administration (VHA) mental health units; the primary root causes for these events; and make recommendations for abating or mitigating these events.
We searched our national database for any reported adverse event that occurred on an inpatient mental health unit between January 1, 2015 and December 31, 2016. We found 87 Root Cause Analysis (RCA) reports and 9780 safety reports. The safety reports were coded for type of event and the RCAs were further coded for underlying causes and severity.
Of the 87 RCA reports, there were 31suicide attempts, 16 elopements, 10 assaults, 8 events involving hazardous items on the unit, 7 falls, 6 unexpected deaths, 3 overdoses and 6 cases coded as "other". For the 9780 safety reports falls were the most common event, followed by medication events, verbal assaults, physical assaults, medical problems and hazardous items on the unit.
As with medical units, patients on mental health units are at risk for many types of adverse events. The same focus on patient safety is just as important for our mental health patients as for our medical patients. Mental health unit staff should undertake a structured assessment of all risk on their units. This broad approach may be more successful than focusing on a particular event type.
虽然对精神卫生病房中的自杀现象进行研究已有很长的历史，但更广泛地研究患者安全问题则相对较新。我们的目的是确定退伍军人事务部（VHA）精神卫生病房中发生的不良事件的类型和相对频率；这些事件的主要根本原因；并提出减轻或缓解这些事件的建议。
我们在全国数据库中搜索了 2015 年 1 月 1 日至 2016 年 12 月 31 日期间在住院精神卫生病房中发生的任何不良事件报告。我们发现了 87 份根本原因分析（RCA）报告和 9780 份安全报告。安全报告按事件类型进行编码，而 RCA 则按根本原因和严重程度进一步编码。
在 87 份 RCA 报告中，有 31 例自杀企图，16 例逃跑，10 例袭击，8 例与病房内危险物品有关的事件，7 例跌倒，6 例意外死亡，3 例药物过量和 6 例被编码为“其他”。在 9780 份安全报告中，跌倒最常见，其次是药物事件、言语攻击、身体攻击、医疗问题和病房内危险物品。
与医疗单位一样，精神卫生病房中的患者也面临许多类型的不良事件的风险。同样，对患者安全的关注对于我们的精神卫生患者和我们的医疗患者同样重要。精神卫生病房工作人员应对其病房中的所有风险进行结构化评估。这种广泛的方法可能比专注于特定事件类型更成功。
