Adverse events occurring on mental health units – 2018-01

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.

Peter D. Mills, Bradley V. Watts, Brian Shiner, Robin R. Hemphill
General Hospital Psychiatry, Volume 50, January–February 2018