Jönköping University, Jönköping, Sweden
Region Jönköpings län, Jönköping, Sweden.
BMJ Open. 2021 Mar 9;11(3):e044068. doi: 10.1136/bmjopen-2020-044068.
To explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed.
Retrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide.
Cohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316).
Demographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcare and actions were categorised by using a coding scheme, analysed per individual and aggregated per cohort. Separate notes were made when a deficiency or action was related to a healthcare-service routine.
The investigations largely adopted a microsystem perspective, focusing on final patient contact, throughout the overall study period. Updating existing or developing new routines as well as educational actions were increasingly proposed over time, while sharing conclusions across departments rarely was recommended.
The mandatory reporting of suicides as potential cases of patient harm was shown to be restricted to information transfer between healthcare providers and the supervisory authority, rather than fostering participative improvement of patient safety for suicidal patients.The similarity in outcomes across the cohorts, regardless of changes in legislation, suggests that the investigations were adapted to suit the structure of the authority's reports rather than the specific incident type, and that no new service improvements or lessons are being identified.
探讨向医疗服务提供者监督机构强制报告自杀事件如何影响医疗服务机构进行的相关调查、从中吸取的经验教训以及是否在患者安全方面进行了任何与预防自杀相关的改进。
对瑞典初级和二级医疗保健向监督机构报告自杀事件后的报告进行回顾性研究。
队列 1：2006 年向监督机构报告的病例，自强制报告自杀事件以来至 2007 年（n=279）。队列 2：2015 年报告的病例，该时期报告工作已经建立（n=436）。队列 3：2017 年 9 月报告的病例，即报告法废除的时间，至 2019 年 11 月（n=316）。
登记自杀前几个月的人口统计学数据和接受的治疗。使用编码方案对报告的医疗保健缺陷和行动进行分类，按个人和按队列进行分析。当缺陷或行动与医疗服务常规有关时，单独记录。
整个研究期间，调查主要采用微观系统视角，重点关注最终患者接触。随着时间的推移，越来越多地提出更新现有或开发新常规以及教育行动，而很少建议在部门之间共享结论。
将自杀作为潜在的患者伤害案例进行强制报告，表明仅限于医疗保健提供者和监督机构之间的信息传递，而不是促进对自杀患者的患者安全的参与式改进。各队列之间结果的相似性，无论立法变化如何，都表明调查适应了监督机构报告的结构，而不是特定事件类型，并且没有发现新的服务改进或经验教训。
