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Since 1995, when this country’s Joint Commission charged hospitals with reporting sentinel events as part of being accredited, inpatient suicide on medical and psychiatric units has been the second most common hospital error, after wrong-site surgery. “Though the numbers of hospital suicides are still tiny,” psychiatrist Jeffrey Janofsky told a Psychiatry grand rounds gathering last month, “any are obviously too many.”
What to do? Results of a recent Harris poll said the general public believes it’s mostly a matter of singling out those health care providers who’re “at fault,” while using better training and malpractice or licensing litigation as medicine’s uplifting and punishing arms. But the nation’s Institute of Medicine—and Janofsky and his Hopkins colleagues—think otherwise. “We’ve come to realize that medical errors are best reduced by improving the system and not by focusing on individual errors,” he says. And being proactive is key.
To that end, the psychiatry department is first targeting a weak link, namely, the way at-risk patients are monitored on hospital units: deciding who’s monitored and how best to monitor, all while improving communication between observers, nurses, doctors and patients.
It’s the system that takes the heat.
Recently, Psychiatry put three solutions in place:
- They analyzed the monitoring process and standardized it (see right) to make it turn less on vigilance and memory and more on communication.
- Nurses and observers now write computerized patient notes for each other at each shift change and at set intervals.
- A new feedback form documents observer impressions and suggestions.
A board game it’s not; this new path for observing patients at risk can save lives.