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Woodnutt S, Hall S, Libberton P, Flynn M, Purvis F, Snowden J. Analysis of England's incident and mental health nursing workforce data 2015-2022. J Psychiatr Ment Health Nurs 2024; 31:716-728. [PMID: 38258945 DOI: 10.1111/jpm.13027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 11/20/2023] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Mental health services report adverse incidents in different ways and the relationship between adverse incidents and the workforce is uncertain. In England, there are national datasets recording all incidents and workforce statistics though there is no peer-reviewed evidence examining recent trends. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Although there has been an overall increase in the number of mental health nurses, more are working in the community and the number of nurses relative to adverse incidents has decreased. There have been service-provision changes but the role of mental health nurses has not significantly changed in this period, and we can therefore assume that their current practice is saturated with risk or increased reporting. To help understand the relationship between nurses and incidents, we need to transform how incidents are recorded in England. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: English mental health services report greater levels of patient-related factors such as self-harm or aggression rather than missed or erroneous care. This makes it difficult to understand if a rise in incident frequency is linked to reporting behaviour, patient risk, unsafe/ineffective care or other reasons and therefore planning workforce deployment to improve care quality is problematic. ABSTRACT INTRODUCTION: There is a paucity of empirical data examining incidents and mental health nurses and the relationship between the two remains uncertain. AIM Comparison of English national data for incidents and nursing workforce to examine recent trends. METHOD Descriptive analysis of two national datasets of incidents and workforce data for England between 2015 and 2022. RESULTS A 46% increase in incidents was found; the leading causes are self-harm and aggressive behaviour. Despite the rise in adverse incident reporting, a 6% increase in mental health nurses was found, with more nurses in community settings than hospitals. DISCUSSION Current services are incident reporting at greater concentrations than in previous years. Patient-related behaviour continues to be most prominently reported, rather than possible antecedent health services issues that may contribute to reporting. Whilst staffing has increased, this does not seem to have kept pace with the implied workload evident in the increase in incident reports. IMPLICATIONS FOR PRACTICE Greater emphasis should be placed on health service behaviour in reporting mechanisms. Self-harm and aggression should continue to be considered adverse outcomes, but causal health service factors, such as missed care, should be present in pooled reporting to help reduce the occurrence of adverse outcomes.
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Affiliation(s)
- Samuel Woodnutt
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Simon Hall
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Paula Libberton
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Matt Flynn
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Francesca Purvis
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Jasmine Snowden
- School of Health Sciences, University of Southampton, Southampton, UK
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Deshpande M, Sinclair JMA, Baldwin DS. Validity of root cause analysis in investigating adverse events in psychiatry. Br J Psychiatry 2023; 222:153-156. [PMID: 36794670 DOI: 10.1192/bjp.2023.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Root cause analysis (RCA), imported from high-reliability industries into health two decades ago, is the mandated methodology to investigate adverse events in most health systems. In this analysis, we argue that the validity of RCA in health and in psychiatry must be established, given the impact of these investigations on mental health policy and practice.
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Affiliation(s)
- Mayura Deshpande
- Faculty of Medicine, University of Southampton, UK and Faculty of Medicine, University of Southampton and Southern Health NHS Foundation Trust, Southampton, UK
| | | | - David S Baldwin
- Faculty of Medicine, University of Southampton, UK; Southern Health NHS Foundation Trust, Southampton, UK and University Department of Psychiatry & Mental Health, University of Cape Town, South Africa
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Quinlivan L, Gorman L, Marks S, Monaghan E, Asmal S, Webb RT, Kapur N. Liaison psychiatry practitioners' views on accessing aftercare and psychological therapies for patients who present to hospital following self-harm: multi-site interview study. BJPsych Open 2023; 9:e34. [PMID: 36803955 PMCID: PMC9970172 DOI: 10.1192/bjo.2023.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate. AIMS To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners. METHOD Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data. RESULTS Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services. CONCLUSIONS Our findings highlight practitioners' views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.
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Affiliation(s)
- Leah Quinlivan
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, UK; and National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Louise Gorman
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, UK; and National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Stephen Marks
- Department of Nursing, Faculty of Health and Education, Manchester Metropolitan University, UK
| | - Elizabeth Monaghan
- National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Sadika Asmal
- National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Roger T Webb
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, UK; and National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Nav Kapur
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, UK; National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK; and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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4
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Choi S, Kim S, Lee H. Factors Affecting Inpatients' Mortality through Intentional Self-Harm at In-Hospitals in South Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3095. [PMID: 36833790 PMCID: PMC9965832 DOI: 10.3390/ijerph20043095] [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: 01/29/2023] [Revised: 02/05/2023] [Accepted: 02/05/2023] [Indexed: 06/18/2023]
Abstract
This study aimed to identify the patient characteristics, comorbidities, risk factors, and means of the self-harm of patients who attempt self-harm in and outside of a hospital, and to determine the characteristics of death by suicide among survival and death patient groups in South Korea. This study used data from the Korean National Hospital Discharge In-depth Injury Survey conducted from 2007 to 2019. In total, 7192 outpatient participants and 43 inpatient participants performed self-harm. Frequency analysis, chi-square tests, Fisher's exact test, and logistic regression analysis were performed using STATA, version 15.0 (StataCorp), and statistical significance was set at 5%. Thirty-one inpatients who performed self-harm survived, and 12 died. Among male inpatients, the older they were, the higher the rates of self-harm and mortality rates due to falls and poisoning if they had comorbidities and financial problems. In addition, the rate of self-harm attempts within a short period after hospitalization was high. Our evidence of the characteristics of patients who performed self-harm in the hospital and the influencing factors of self-harm can be used as primary data for predicting patients at a high risk of self-harm and for creating preventative policies to reduce the risk of self-harm among inpatients in South Korea.
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Affiliation(s)
- Sulki Choi
- College of Applied Health Science, Biomedical Health Information Science, University of Illinois at Chicago, 1919 W Taylor St, Chicago, IL 60612, USA
| | - Sangmi Kim
- Department of Health Management, Jeonju University, 303 Cheonjam-ro, Wansan-gu, Jeonju-si 55069, Republic of Korea
| | - Hyunsook Lee
- Department of Health Administration, Kongju National University, 56 Gongjudaehak-ro, Singwan-dong, Gongju-si 32588, Republic of Korea
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Sunnqvist C, Berngarn A, Ezinne Ekezie P, Lundgren E, Nilsson E, Örmon K. A pilot evaluation of a prehospital emergency psychiatric unit: The experiences of patients, psychiatric and mental health nurses, and significant others. Perspect Psychiatr Care 2022; 58:2255-2262. [PMID: 35148425 PMCID: PMC9790504 DOI: 10.1111/ppc.13055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To explore the significance of the alliance with the Prehospital Emergency Psychiatric Unit for patients, psychiatric and mental health nurses, and significant others, and to evaluate their experiences of treatment and care. DESIGN AND METHODS A qualitative inductive interview study with 11 participants: four patients, six nurses, and one significant other. The interviews were analyzed with content analysis. FINDINGS The analysis resulted in four subcategories: To be met with respect, presence and time, knowledge and experience, and feeling of support, and one category: A psychiatric team with knowledge and experience creating stability and a sense of self-worth. PRACTICE IMPLICATION The Prehospital Emergency Psychiatric Unit enables a safe, person-centered service.
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Affiliation(s)
- Charlotta Sunnqvist
- Department of Care Sciences, Faculty of Health and Society, Malmö University, Malmö, Sweden
| | | | | | - Emma Lundgren
- Office of Psychiatry and Habilitation, Region Skane, Malmö, Sweden
| | - Emma Nilsson
- Office of Psychiatry and Habilitation, Region Skane, Malmö, Sweden
| | - Karin Örmon
- Department of Care Sciences, Faculty of Health and Society, Malmö University, Malmö, Sweden.,Office of Psychiatry and Habilitation, Region Skane, Malmö, Sweden
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Berg SH, Rørtveit K, Walby FA, Aase K. Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis. BMC Health Serv Res 2022; 22:967. [PMID: 35906685 PMCID: PMC9336074 DOI: 10.1186/s12913-022-08282-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 07/03/2022] [Indexed: 11/25/2022] Open
Abstract
Background The prevailing patient safety strategies in suicide prevention are suicide risk assessments and retrospective reviews, with emphasis on minimising risk and preventing adverse events. Resilient healthcare focuses on how everyday clinical practice succeeds and emphasises learning from practice, not from adverse events. Yet, little is known about resilient practices for suicidal inpatients. The aim of the study is to draw upon the perspectives of patients and healthcare professionals to inform the conceptual development of resilient practices in inpatient suicide prevention. Methods A narrative synthesis was conducted of findings across patients and healthcare professionals derived from a qualitative case study based on interviews with patients and healthcare professionals in addition to a systematic literature review. Results Three sub-themes categorise resilient practices for healthcare professionals and for patients hospitalised with suicidal behaviour: 1) interactions capturing non-verbal cues; 2) protection through dignity and watchfulness; and 3) personalised approaches to alleviate emotional pressure. The main theme, the establishment of relationships of trust in resilient practices for patients in suicidal crisis, is the foundation of their communication and caring. Conclusion Clinical practice for patients hospitalised with suicidal behaviour has characteristics of complex adaptive systems in terms of dynamic interactions, decision-making under uncertainty, tensions between goals solved through trade-offs, and adaptations to patient variability and interpersonal needs. To improve the safety of patients hospitalised with suicidal behaviour, variability in clinical practice should be embraced. Trial registration https://doi.org/10.1136/bmjopen-2016-012874
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Affiliation(s)
- Siv Hilde Berg
- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Kjell Arholmsgate 43, N-4036, Stavanger, Norway. .,Clinics of Adult Mental Health Care, Stavanger University Hospital, P.O. Box 8100, N-4068, Stavanger, Norway.
| | - Kristine Rørtveit
- Milieu Therapy and Mental Health Nursing Research Group, Clinics of Adult Mental Health Care, Stavanger University Hospital, P.O. Box 8100, N-4068, Stavanger, Norway.,Life Phenomena and Caring Research Group, Department of Caring and Ethics, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway
| | - Fredrik A Walby
- National Centre for Suicide Research and Prevention, Faculty of Medicine, University of Oslo, Sognsvannsveien 21, Building 12, N-0320, Oslo, Norway
| | - Karina Aase
- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Kjell Arholmsgate 43, N-4036, Stavanger, Norway
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Waddell AE, Gratzer D. Patient Safety and Mental Health-A Growing Quality Gap in Canada. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:246-249. [PMID: 34378413 PMCID: PMC9099078 DOI: 10.1177/07067437211036596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient safety research in mental health has focused mainly on suicide and violence risk at the expense of other domains of safety. In Canada, we lack a national strategy or research agenda for this important area. This piece calls on psychiatrists to consider the scope of missed opportunities in patient safety in current practice and presents how to begin to consider the safety of our patients in a systematic manner.
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Affiliation(s)
- Andrea E Waddell
- General Adult Psychiatry & Health Systems, 7978CAMH, Toronto, Ontario.,Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - David Gratzer
- General Adult Psychiatry & Health Systems, 7978CAMH, Toronto, Ontario.,Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario
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Scarth B, Pavlova A, Hetrick SE, Witt KG, Hawton K, Fortune S. Service users’ experiences of emergency care following an episode of self-harm: a mixed evidence synthesis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Bonnie Scarth
- WellSouth, Primary Care Organisation; Dunedin New Zealand
| | - Alina Pavlova
- Psychological Medicine; University of Otago; Dunedin New Zealand
| | - Sarah E Hetrick
- Department of Psychological Medicine, Faculty of Medical and Health Sciences; The University of Auckland; Auckland New Zealand
- Children and Young People Satellite, Cochrane Common Mental Disorders; The University of Auckland; Auckland New Zealand
| | - Katrina G Witt
- Orygen; Parkville, Melbourne Australia
- Centre for Youth Mental Health; The University of Melbourne; Melbourne Australia
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry; University of Oxford; Oxford UK
| | - Sarah Fortune
- Department of Social and Community Health, Faculty of Medical and Health Sciences; The University of Auckland; Auckland New Zealand
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9
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First responder, clinician, and non‐clinical support staff knowledge, attitudes, and behaviours towards people presenting for emergency care following self‐harm: a mixed evidence synthesis. Cochrane Database Syst Rev 2021; 2021:CD014939. [PMCID: PMC8668017 DOI: 10.1002/14651858.cd014939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
This is a protocol for a Cochrane Review (qualitative). The objectives are as follows: The objectives of this review are threefold, as follows. Firstly, to assess the content of knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff towards service users with SH presentations. Secondly, to understand how service user and staff characteristics (e.g. age, gender, sociodemographic background), type of SH presentation (e.g. method, repetition), and contextual factors (e.g. hospital environment, presence of bystanders) affect the knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff in providing acute care. Thirdly, to assess whether clinicians' knowledge, attitudes, and behaviours have evolved over time.
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10
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Kapur N, Gorman LS, Quinlivan L, Webb RT. Mental health services: quality, safety and suicide. BMJ Qual Saf 2021; 31:419-422. [PMID: 34607913 DOI: 10.1136/bmjqs-2021-013532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Nav Kapur
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK, Manchester, UK .,Centre for Mental Health and Safety, University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Louise S Gorman
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK, Manchester, UK.,Centre for Mental Health and Safety, University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Leah Quinlivan
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK, Manchester, UK.,Centre for Mental Health and Safety, University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Roger T Webb
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK, Manchester, UK.,Centre for Mental Health and Safety, University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
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Guseva Canu I, Bovio N, Wild P, Bopp M. Identification of socio-demographic, occupational, and societal factors for guiding suicide prevention: A cohort study of Swiss male workers (2000-2014). Suicide Life Threat Behav 2021; 51:540-553. [PMID: 33724520 DOI: 10.1111/sltb.12746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION We modeled suicidal rate among Swiss working-age males, considering three groups of factors at socio-demographic, occupational, and societal levels jointly. Our goal was twofold: to verify the effect of occupation after adjustment for non-occupational factors and to identify protective and risk factors relevant for suicide prevention in working male adults. METHODS The study population included all men aged [18-65] years at the 2000 population census and followed up within the Swiss National Cohort (SNC). The risk of suicide was modeled using Poisson regression. RESULTS The cohort comprised 1,534,564 men and 4371 deaths by suicide. Suicide rate varied significantly according to age, civil status, nationality, highest education achieved, and socio-professional category at socio-demographic level; occupation, occupational activity branch, weekly working hours, and home-to-work commute time at occupational level; calendar period of death, region, religious affiliation, and volunteering activity at societal level. After adjustment for non-occupational factors, agricultural and fishery laborers, military and civil security workers, and health and social workers were identified as high-risk groups with respect to suicide. CONCLUSION This study evidenced a complex web of factors at socio-demographic, occupational, and societal levels behind the suicide in Swiss male workers and identified the most at-risk groups, deserving targeted prevention efforts.
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Affiliation(s)
- Irina Guseva Canu
- Department of Occupational and Environmental Health, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Nicolas Bovio
- Department of Occupational and Environmental Health, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Pascal Wild
- Department of Occupational and Environmental Health, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,French National Research and Safety Institute for the Prevention of Occupational Accidents and Diseases (INRS, Vandoeuvre Les Nancy, France
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zürich, Switzerland
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Fröding E, Gäre BA, Westrin Å, Ros A. Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective. BMJ Open 2021; 11:e044068. [PMID: 33687954 PMCID: PMC7944973 DOI: 10.1136/bmjopen-2020-044068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed. DESIGN AND SETTINGS Retrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide. PARTICIPANTS Cohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316). PRIMARY AND SECONDARY OUTCOME MEASURES Demographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcare and actions were categorised by using a coding scheme, analysed per individual and aggregated per cohort. Separate notes were made when a deficiency or action was related to a healthcare-service routine. RESULTS The investigations largely adopted a microsystem perspective, focusing on final patient contact, throughout the overall study period. Updating existing or developing new routines as well as educational actions were increasingly proposed over time, while sharing conclusions across departments rarely was recommended. CONCLUSIONS The mandatory reporting of suicides as potential cases of patient harm was shown to be restricted to information transfer between healthcare providers and the supervisory authority, rather than fostering participative improvement of patient safety for suicidal patients.The similarity in outcomes across the cohorts, regardless of changes in legislation, suggests that the investigations were adapted to suit the structure of the authority's reports rather than the specific incident type, and that no new service improvements or lessons are being identified.
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Affiliation(s)
- Elin Fröding
- Jönköping University, Jönköping, Sweden
- Region Jönköpings län, Jönköping, Sweden
| | - Boel Andersson Gäre
- Jönköping University, Jönköping, Sweden
- Futurum, Region Jönköpings län, Jönköping, Sweden
| | - Åsa Westrin
- Division of Psychiatry, Department of Clinical Sciences, Lund University, Lund, Sweden
- Region Skåne, Psychiatry Research Skåne, Office for Psychiatry and Habilitation, Lund, Sweden
| | - Axel Ros
- Jönköping University, Jönköping, Sweden
- Region Jönköpings län, Jönköping, Sweden
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