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Watts BV, Calloway K. Implementation of Quality Improvement System in a National Health System. Am J Med Qual 2024; 39:183-187. [PMID: 38992908 DOI: 10.1097/jmq.0000000000000195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
There is a continued need to improve the quality of health care services and the health outcomes associated with that care. Quality improvement model and the Learning Health System framework have emerged as potential methods to achieve the goals of better care and enhanced outcomes. Few practical tools and approaches have been developed to assist with the initiation of quality improvement and development of a Learning Health System. The Department of Veterans Affairs developed and deployed a national system to assist and organize improvement projects and serve as a database for learning. During its first 5 years of use, 7397 quality improvement projects were completed using the electronic tool. National implementation of a structured tool for quality improvement is possible.
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Affiliation(s)
- Bradley V Watts
- Veterans Rural Health Resource Center, VA Office of Rural Health, Washington, DC
- Department of Mental Health, White River Junction VA Medical Center, White River Junction, VT
- Department of Psychiatry, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Kay Calloway
- Systems Redesign and Quality Improvement, Veterans Integrated Service Network 22, Long Beach, CA
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Thiruvalluru RK, Edgcomb JB, Brooks JO, Pathak J. Risk of suicide attempts and self-harm after 1.4 million general medical hospitalizations of men with mental illness. J Psychiatr Res 2023; 157:50-56. [PMID: 36436428 PMCID: PMC10395648 DOI: 10.1016/j.jpsychires.2022.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/17/2022] [Accepted: 10/17/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The short-term risk of suicide after medical hospital discharge is four times higher among men compared with women. As previous work has identified female-specific antecedents of suicide-related behavior after medical hospitalization of women with serious mental illness, we examined predictors among a similar population of men with multimorbidity. METHODS Classification and regression tree (CART) models were developed and validated using electronic health records (EHRs) from 1,423,161 medical (non-psychiatric) hospitalizations of men ≥ 18-years-old with an existing diagnosis of a depressive disorder, bipolar disorder, or chronic psychosis. Hospitalizations occurred between 2009 and 2017. Risk groups were evaluated using an independent testing set. The primary outcome was readmission within one year associated with ICD-9 or -10 code for self-harm or attempt. RESULTS The 1-year readmission rate for intentional self-harm and suicide attempt was 3.9% (55,337/1,423,161 hospitalizations). The classification model discriminated risk with area under the curve (AUC) 0.73 (Confidence Interval [95%CI] 0.68-0.74), accuracy 0.82 (95%CI 0.71-0.83), sensitivity 82.6% (95%CI 81.2-84), and specificity 83.1% (95%CI 81.7-84.5). Strongest predictors were medical comorbidity, prior self-harm, age, and prior hospitalization. Men with greater medical comorbidity burden and prior self-harm were at highest risk (Odds Ratio [OR] 3.10, 95%CI 3.02-3.18), as were men < 62-years-old with few medical comorbidities (OR 1.11 95%CI 1.08-1.13). LIMITATIONS The study focused on medical hospitalizations for suicide attempt and thus captured only severe attempts resulting in hospitalization. CONCLUSIONS After medical hospitalization, men with serious mental illness experienced a high risk of self-harm (1:25 hospitalizations). Risk was particularly elevated among younger patients without prior medical conditions and older patients with medical comorbidity and prior self-harm.
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Affiliation(s)
- Rohith Kumar Thiruvalluru
- Division of Health Informatics, Department of Population Health Sciences, Weill Cornell Medicine, 402 E. 67th St., New York, NY, 10065, USA
| | - Juliet Beni Edgcomb
- UCLA-Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, 760 Westwood Plz, Los Angeles, CA, 90095, USA.
| | - John O Brooks
- UCLA-Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, 760 Westwood Plz, Los Angeles, CA, 90095, USA
| | - Jyotishman Pathak
- Division of Health Informatics, Department of Population Health Sciences, Weill Cornell Medicine, 402 E. 67th St., New York, NY, 10065, USA
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Svensson J. Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review. J Patient Saf 2022; 18:245-252. [PMID: 34347739 PMCID: PMC9359776 DOI: 10.1097/pts.0000000000000885] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm. METHOD A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy. RESULTS The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization. CONCLUSIONS The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.
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Affiliation(s)
- Jakob Svensson
- From the Division of Risk Management and Societal Safety, Lund University, Sweden
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Karel MJ, Wray LO, Adler G, Hannum AOR, Luci K, Brady LA, McGuire MH. Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations. Clin Gerontol 2022; 45:252-271. [PMID: 31971092 DOI: 10.1080/07317115.2020.1716910] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.
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Affiliation(s)
- Michele J Karel
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs (VA) Central Office, Washington, DC, United States
| | - Laura O Wray
- VA Center for Integrated Healthcare, VA Western New York Health Care System, Buffalo, New York, United States.,Jacobs School of Medicine and Biomedical Sciences, SUNY University at Buffalo, Buffalo, New York, United States
| | - Geri Adler
- VA South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, United States
| | - Alisa O' Riley Hannum
- Mental Health Service, VA Eastern Colorado Healthcare System, Colorado Springs, Colorado, United States
| | - Katherine Luci
- Center for Aging and Neurocognitive Services, Salem VA Medical Center, Salem, Virginia, United States.,Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, Blacksburg, Virginia, United States
| | - Laura A Brady
- Jacobs School of Medicine and Biomedical Sciences, SUNY University at Buffalo, Buffalo, New York, United States
| | - Marsden H McGuire
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs (VA) Central Office, Washington, DC, United States
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Ramsey C, Galway K, Davidson G. Implementing changes after patient suicides in mental health services: A systematic review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:415-431. [PMID: 33761169 DOI: 10.1111/hsc.13332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/15/2021] [Accepted: 02/04/2021] [Indexed: 06/12/2023]
Abstract
Suicides by mental health patients account for around a quarter of all suicides (Walby et al, 2018). Within services a range of approaches have been developed and implemented to reduce the risk of patient suicides. After every patient death by suicide, a review is carried out to identify recommendations which may assist in preventing future suicides. It is therefore important to identify the most effective methods for implementing these recommendations. The objective of this systematic review, completed in Northern Ireland, was to identify how recommendations from Serious Adverse Incident (SAI) reviews can be effectively implemented to contribute to reducing deaths by suicide within mental health services. Eleven electronic databases were searched for relevant work from 1 January 2005-30 November 2020. Quantitative, qualitative and mixed methods studies were included. A narrative synthesis was carried out of published and unpublished work on the effectiveness of implementing recommendations, after a death by suicide in mental health services. The review, which includes 41 published papers and reports, found that the literature is focused on producing recommendations to reduce future risk of suicide in mental health services. There is a lack of focus on the extent and effectiveness of the implementation of these. Recommendations have often not been tested or operationalised, limiting the translational value of these contributions. Leadership and culture are also identified as key drivers for change in mental health services. This review demonstrates that high quality research is being complete in this area, however, the majority of published research presents recommendations from reviews of mental health patient suicides. There is a lack of research focusing on implementing recommendations and evaluation of implementation, once recommendations have been made.
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Affiliation(s)
- Colette Ramsey
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Karen Galway
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Gavin Davidson
- School of Social Sciences, Education and Social Work, Queen's University, Belfast, UK
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Whitt ZT, Sturgeon T, Rattermann MJ, Salyers M, Zapolski T, Cyders MA. Mapping recovery: A qualitative node map approach to understanding factors proximal to relapse among adolescents in a recovery high school. J Subst Abuse Treat 2022; 138:108750. [DOI: 10.1016/j.jsat.2022.108750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/14/2021] [Accepted: 01/28/2022] [Indexed: 10/19/2022]
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Schmidt EM, Wright D, Cherkasova E, Harris AHS, Trafton J. Evaluating and Improving Engagement in Care After High-Intensity Stays for Mental or Substance Use Disorders. Psychiatr Serv 2022; 73:18-25. [PMID: 34106740 DOI: 10.1176/appi.ps.202000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This interrupted time-series analysis examined whether activating a quality measure, supported by education and a population management tool, was associated with higher postdischarge engagement (PDE) in outpatient care after inpatient and residential stays for mental or substance use disorder care. METHODS Discharges from October 2016 to May 2019 were identified from national Veterans Health Administration (VHA) records representing all 140 VHA health care systems. Engagement was defined as multiple mental or substance use disorder outpatient visits in the 30 days postdischarge. The number of such visits required to meet the engagement definition depended on a patient's suicide risk and acuity level of inpatient or residential treatment. Health care system-level performance was calculated as the percentage of qualifying discharges with 30-day PDE. A segmented mixed-effects linear regression model tested whether monthly health care system performance changed significantly after activation of the PDE measure (activation rollout period, October-December 2017). RESULTS A total of 322,344 discharges qualified for the measure. In the regression model, average health care system performance was 65.6% at the beginning of the preactivation period (October 2016) and did not change significantly in the following 12 months. Average health care system performance increased by 5.7% (SE=0.8%, p<0.001) after PDE measure activation and did not change significantly thereafter-a difference representing 11,464 more patients engaging in care than would have without activation of the measure. CONCLUSIONS Results support use of this measure, along with education, technical assistance, and population management tools, to improve engagement after discharge from residential and inpatient mental and substance use disorder treatment.
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Affiliation(s)
- Eric M Schmidt
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
| | - David Wright
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
| | - Elena Cherkasova
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
| | - Alex H S Harris
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
| | - Jodie Trafton
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), Menlo Park, California (Schmidt, Wright, Cherkasova, Trafton); Center for Innovation to Implementation, Health Services Research and Development (HSR&D), VHA, VA Palo Alto Health Care System, Menlo Park, California (Schmidt, Harris); Department of Surgery (Harris) and Department of Psychiatry and Behavioral Sciences (Trafton), School of Medicine, Stanford University, Stanford, California
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Michaud L, Stiefel F, Moreau D, Dorogi Y, Morier-Genoud A, Bourquin C. Suicides in Psychiatric Patients: Identifying Health Care-Related Factors through Clinical Practice Reviews. Arch Suicide Res 2020; 24:S150-S164. [PMID: 30856364 DOI: 10.1080/13811118.2019.1586606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The objective of this study was to identify health care-related factors associated with death by suicide in psychiatric patients and to gain insight into clinician views on how to deal with suicidality. The study material derived from a clinician committee in a psychiatric department reviewing every outpatient and inpatient suicide in a standardized way. Reports' conclusions and corresponding plenary discussion minutes regarding 94 suicides were analyzed using inductive thematic content analysis. Health care-related factors were categorized into 4 themes: patient evaluation, patient management, clinician training, and involvement of relevant non-clinical partners. Clinician views on the themes were expressed through statements (i) promoting or restricting an aspect of care (here called recommendations), which mainly followed existing guidelines and were consensual and (ii) without precise indication (here called comments), which departed from mainstream opinions or addressed topics not covered by existing policy. Involvement of non-clinical partners emerged as a new key issue for suicide prevention in psychiatric departments and should be openly discussed with patients. Clinicians preferred balanced conclusions when they reviewed suicide cases.
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Affiliation(s)
- Laurent Michaud
- McGill Group for Suicide Studies, Douglas Mental Health University Institute, Pavilion Frank B. Common, Montreal (Québec), Canada.,Psychiatric Liaison Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Friedrich Stiefel
- Psychiatric Liaison Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Delphine Moreau
- School of Health Science of Vaud (HESAV), University of Applied sciences and Art of Western Switzerland, Lausanne, Switzerland
| | - Yves Dorogi
- Psychiatric Liaison Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Anouk Morier-Genoud
- Psychiatric Liaison Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Céline Bourquin
- Psychiatric Liaison Service, Lausanne University Hospital, Lausanne, Switzerland
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Riblet NB, Kenneally L, Shiner B, Watts BV. Health Care Processes Contributing to Suicide Risk in Veterans During and After Residential Substance Abuse Treatment. J Dual Diagn 2019; 15:217-225. [PMID: 31253073 PMCID: PMC6868319 DOI: 10.1080/15504263.2019.1629053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/06/2019] [Accepted: 05/21/2019] [Indexed: 01/19/2023]
Abstract
Objective: Substance use disorders are an important risk factor for suicide. While residential drug treatment programs improve clinical outcomes for substance use disorders, less is known about the role of related health care processes in contributing to suicide risk. These data may help to inform strategies to prevent suicide during and after residential treatment.Methods: A retrospective analysis was conducted on root-cause analysis (RCA) reports of suicide in veterans occurring within 3 months of discharge from a residential drug treatment program that were reported to a Veterans Affairs facility between 2001 and 2017. Demographic information such as age, gender, and psychiatric comorbidity were abstracted from each report. In addition, an established codebook was used to code root causes from each report. Root causes were grouped into categories in order to characterize the key system and organizational-level processes that may have contributed to the suicide.Results: A total of 39 RCA reports of suicide occurring within 3 months after discharge from a residential drug treatment program were identified. The majority of decedents were men and the average age was 42.9 years (SD = 11.2). The most common method of suicide was overdose (33%) followed by hanging (28%). Most suicides occurred in close proximity to discharge, with 56% (n = 22) occurring within seven days of discharge and 36% (n = 14) occurring within 48 hours of discharge. The most common substances used by decedents prior to admission were alcohol or opiates. RCA teams identified a total of 140 root causes and the majority were due to problems with suicide risk assessment (n = 32, 22.9%). Non-engagement with treatment during (n = 20, 14.3%) and after the residential stay (n = 18, 12.9%) was also highlighted as an important concern. Finally, several reports raised concerns that a discharge prior to treatment completion or a precipitous discharge due to program violation negatively impacted treatment outcomes.Conclusions: Efforts to prevent suicide in the period following discharge from a residential drug treatment program should focus on addressing suicide risk factors during admission and helping patients engage more fully in substance use disorder treatment.
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Affiliation(s)
- Natalie B Riblet
- Mental Health, Veterans Affairs Medical Center, White River Junction, Vermont, USA
- Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Psychiatry, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - Lauren Kenneally
- Nursing, Norwich University School of Nursing, Northfield, Vermont, USA
| | - Brian Shiner
- Mental Health, Veterans Affairs Medical Center, White River Junction, Vermont, USA
- Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Psychiatry, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
- Mental Health, National Center for PTSD, White River Junction, Vermont, USA
| | - Bradley V Watts
- Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Patient Safety, National Center for Patient Safety, Ann Arbor, Michigan, USA
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Aboumrad M, Shiner B, Riblet N, Mills PD, Watts BV. Factors contributing to cancer-related suicide: A study of root-cause analysis reports. Psychooncology 2018; 27:2237-2244. [DOI: 10.1002/pon.4815] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/04/2018] [Accepted: 06/08/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Maya Aboumrad
- The National Center for Patient Safety; White River Junction VT United States
| | - Brian Shiner
- Geisel School of Medicine at Dartmouth; Hanover NH United States
- The Dartmouth Institute for Health Policy and Clinical Practice; Lebanon NH United States
- Veterans Affairs Medical Center; White River Junction VT United States
| | - Natalie Riblet
- Geisel School of Medicine at Dartmouth; Hanover NH United States
- The Dartmouth Institute for Health Policy and Clinical Practice; Lebanon NH United States
- Veterans Affairs Medical Center; White River Junction VT United States
| | - Peter D. Mills
- Geisel School of Medicine at Dartmouth; Hanover NH United States
- Veterans Affairs Medical Center; White River Junction VT United States
| | - Bradley V. Watts
- The National Center for Patient Safety; White River Junction VT United States
- Geisel School of Medicine at Dartmouth; Hanover NH United States
- Veterans Affairs Medical Center; White River Junction VT United States
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