From the Veterans' Health Administration National Center for Patient Safety, Ann Arbor, Michigan.
J Patient Saf. 2021 Dec 1;17(8):e821-e828. doi: 10.1097/PTS.0000000000000884.
United States veterans face an even greater risk of homelessness and associated medical conditions, mental health conditions, and fatal and nonfatal overdose as compared with nonveterans. Beginning 2009, the Department of Veterans Affairs developed a strategy and allocated considerable resources to address veteran homelessness and the medical conditions commonly associated with this condition.
This study aimed to examine the Veterans Health Administration National Center for Patient Safety database for patient safety events in the homeless veteran population to mitigate future risk and inform policy.
This was a retrospective, descriptive quality improvement study of reported patient safety events of homeless veterans enrolled in Veterans Health Administration care between January 2012 and August 2020. A validated codebook was used to capture individual patient characteristics, location and type of event, homeless status, and root causes of the events and proposed actions for prevention.
Suicide attempt or death, elopement, delay in care, and unintentional opioid overdose were the most common adverse events reported for this population. Root causes include issues with policies, procedures, and care processes for managing and evaluating homeless patients for the risk of suicidal or overdose behaviors and discharge, poor interdisciplinary communication, and coordination of patient care. Actions included standardization of procedures for discharge, overdose and suicide risk, staff education, and purchasing new equipment.
Suicide and opioid overdose are the most serious reported health care-related adverse events in the unsheltered homeless veteran population. Failures to recognize homelessness status, communicate status, and coordinate available services are root causes of these events.
与非退伍军人相比，美国退伍军人面临更大的无家可归风险以及相关的医疗状况、心理健康状况、致命和非致命药物过量风险。自 2009 年以来，美国退伍军人事务部制定了一项战略并分配了大量资源，以解决退伍军人无家可归问题以及与这种情况相关的常见医疗状况。
本研究旨在调查退伍军人健康管理局国家患者安全中心数据库中无家可归退伍军人患者的患者安全事件，以降低未来风险并为政策提供信息。
这是一项回顾性、描述性的质量改进研究，研究对象为 2012 年 1 月至 2020 年 8 月期间在退伍军人健康管理局接受治疗的无家可归退伍军人患者报告的患者安全事件。使用经过验证的代码本捕获个体患者特征、事件地点和类型、无家可归状态以及事件的根本原因和预防建议。
自杀企图或死亡、擅自离院、治疗延误和非故意阿片类药物过量是该人群报告的最常见不良事件。根本原因包括管理和评估无家可归患者自杀或药物过量风险以及出院的政策、程序和护理流程问题、跨学科沟通不良以及患者护理协调不善。行动包括为出院、药物过量和自杀风险制定标准化程序、员工教育和购买新设备。
自杀和阿片类药物过量是无家可归的退伍军人中最严重的报告医疗相关不良事件。未能识别无家可归状态、沟通状态和协调可用服务是这些事件的根本原因。
