Last year The Joint Commission issued a Sentinel Event Alert to hospitals urging them to do a better job of identifying suicidal ideation in patients, this year the accreditor is doubling down, issuing specific warnings in Joint Commission publications and FAQs outlining concerns about ligature, or hanging, risks.
The use of a standardized handoff checklist tool improves time efficiency, reduces medication discrepancies, and there is a reduction of deficits or missed communications in the handoff process.
For 11 months, two AHS hospitals tried out an automated system called the Automated All-Cause Harm Trigger System (ACHTS). The system’s software uses 41 algorithms to monitor electronic medical records (EMR) for signs that harm has befallen a patient, with flagged charts sent to a reviewer to examine. By the end of the study, the ACHTS caught 2,696 cases of patient harm, compared to the 132 harms caught using the old sampling method.
Intervention efforts included additional suicide screening, suicide prevention info, and a personalized safety plan for dealing with future suicide ideation, and periodic telephone follow-ups. Those who received these interventions made 30% fewer total suicide attempt than others.
In 2014, the Parkland Health and Hospital System (PHHS) in Dallas became the first in the nation to establish a universal suicide screening program (SSP) in all its departments. The program screens every admitted patient for suicidal ideation, regardless of the patient’s chief complaint or estimated risk.
The conversation around tracking medical errors highlights a lack of safety cultures resulted in the question: why aren’t we doing more research into strategies that can reduce medical errors?
People can grow used to anything, even alarms. Such is the danger of alarm fatigue; when excessive and nuisance alerts cause healthcare staff to become desensitized.
In November 2016, a study published in the British Journal of Anesthesia (BJA) found that each year there are 50 million postoperative complications worldwide.
Suicides were the third most common sentinel event of 2015, with 95 reported cases in 2015’s Sentinel Event Statistics. The total number of patient suicides reported to The Joint Commission is now up to 1,184 since the start of the decade.
By Susan M. Scott, BSN, MSN, RN, WOC Over the past five years, the incidence of perioperative hospital-acquired pressure injuries (HAPI) has increased (Chen, Chen, & Wu, 2012), causing patients pain and suffering and costing the U.S. healthcare system $11 billion per year (Brem et al., 2010). Pressure injuries (previously referred to as pressure ulcers) … Continued