An Eye on Suicide
Date: March 11, 2009
52,712. That’s how many patients have passed through Hopkins hospital’s psychiatric inpatient units since 1979, amassing what surely must be some kind of record for a large inner-city medical center: no suicides.
“We don’t know that ours is a record; we’re looking into it,” says psychiatrist Geetha Jayaram. “but it would help confirm what we believe, that steps we’re taking are right ones to keep patients safe.”
Jayaram has been instrumental in that safety. For 19 years, she’s worked to improve the overall welfare of those on the Meyer units under her administrative and clinical care, giving equal weight to their status as both patients and sufferers of psychiatric illness. As the psychiatry department’s physician advisor, a gritty role that, in part, demands scrutiny of anything gone wrong, Jayaram has pushed for built-in safeguards and review. She embraced root cause analysis—solving problems by digging down to an incident’s source—before it became routine.
Her tactics are as broad as improving education—repeatedly coaching residents to recognize gathering clouds of violence in patients or to assess suicide risk. Or they’re as pointed as telling observers to make sure at-risk patients’ hands are in full sight.
Recently, however, partly because Hopkins’ Peter Pronovost put a systems approach to medical safety in the national spotlight, but also because there’s institutional support, Jayaram and colleague Jeff Janofsky (below) initiated more formal steps to reduce suicide risk. While colleagues in surgery locked in new protocols to stop wrong-site operations, for example, Psychiatry has adopted the proactive FMEA (failure mode and effects analysis) approach to safety.
Last fall, a rare brainstorming session with unit nurses, social workers, occupational therapists, physicians and patient observers let them pinpoint and rank 91 things routinely done or left undone that could put patients at risk.
What did they designate as the weakest link in suicide prevention?
As new chair of the American Psychiatric Association’s patient safety committee, Jayaram’s in a good place to explain:
Suicide is, of course, a horror and a wound to humanity. But there’s value in viewing it dispassionately.
As a signal, you mean? Yes. You learn quickly, when seeing different hospitals as a consultant, that an inpatient suicide is the tip of a wedge. The base reflects a system that’s damaged.
What has helped Hopkins so far?
In part, I think, a lot of looking over our shoulders. We’ve tried to address every problem area the Joint Commission has singled out. So you assess patients thoroughly and often. All at-risk patients who come on the unit are immediately held under heightened observation, for example, until there’s collateral information to help us evaluate them. Our attending physicians must interview every patient daily and write notes. Also, we’ve created a patient safety plan that our nurses use to rate risk of violence. It lays down defusing tactics, should the need arise, that partly come from asking patients, How can we make you feel calm?
Hopkins has intense sit-down rounds that involve a patient’s entire treatment team. When the occupational therapist tells you, I saw Mr. Jones today and he talked a great deal about death, that’s crucial. And you hit home that every visitor, even VIPs, are treated politely but as potential sources of lethal agents. A security guard oversees each unit.
Yes. Every hospital has them. Fortunately, there are few enough for me to remember them all. Determined patients can think of a million things: One patient snatched a trash bag and put it over her head, even as an observer was watching. We’ve eliminated trash bags.
Which brings us to the brainstorming session. What was the weakest link?
It centered on the observers, those hired to keep varying degrees of watch on patients at risk. We all agreed, even the observers, that communication between them, nurses and patients wasn’t always clear and orderly. Now observers are vetted and trained by nurses. We document hand-offs to the next shift. And everyone’s patient observations are set down electronically.
So your aim is a culture of safety.
Yes. It’s a shift in thinking to see errors properly as flaws in the system. You remove processes that rely on employee endurance or memory. You stop blaming and shaming people. That frees everyone to become truly invested in patient care.
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