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Fröding E, Vincent C, Andersson-Gäre B, Westrin Å, Ros A. Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention. Arch Suicide Res 2024; 28:1-19. [PMID: 36259504 DOI: 10.1080/13811118.2022.2133652] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward. METHODS Narrative literature review. RESULTS Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety. CONCLUSIONS There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.HIGHLIGHTSThere are weaknesses in the current approaches to investigations of suicide.A paradigm shift in investigations is needed to contribute to a better understanding of suicide.New knowledge of suicidal behavior, prevention, and patient safety must be applied.
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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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Rex M, Brezicka T, Carlström E, Waern M, Ali L. Coexisting service-related factors preceding suicide: a network analysis. BMJ Open 2022; 12:e050953. [PMID: 35450889 PMCID: PMC9024253 DOI: 10.1136/bmjopen-2021-050953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The overall objective was to analyse service-related factors involved in the complex processes that precede suicide in order to identify potential targets for intervention. DESIGN AND SETTING Explorative network analysis study of post-suicide root cause analysis data from Swedish primary and secondary healthcare. PARTICIPANTS 217 suicide cases reported to the Swedish national root cause analysis database between 2012 and 2017. PRIMARY AND SECONDARY OUTCOME MEASURES A total of 961 reported incidents were included. Demographic data and frequencies of reported deficiencies were registered. Topology, centrality indices and communities were explored for three networks. All networks have been tested for robustness and accuracy. RESULTS Lack of follow-up, evaluations and insufficient documentation issues emerged as central in the network of major themes, as did the contributing factors representing organisational problems, failing procedures and miscommunication. When analysing the subthemes of deficiencies more closely, disrupted treatments and staffing issues emerged as prominent features. The network covering the subthemes of contributing factors also highlighted discontinuity, fragile work structures, inadequate routines, and lack of resources and relevant competence as potential triggers. However, as the correlation stability coefficients for this network were low, the results need further investigation. Four communities were detected covering nodes for follow-up, evaluation, cooperation, and procedures; communication, documentation and organisation; assessments of suicide risk and psychiatric status; and staffing, missed appointments and declined treatment. CONCLUSION The results of this study suggest that healthcare providers may improve patient safety in suicide preventive pathways by taking active measures to provide regular follow-ups to patients with elevated suicide risk. In some cases, declined or cancelled appointments could be a warning sign. Tentative results show organisational instability, in terms of work structure, resources and staffing, as a potential target for intervention, although this must be more extensively explored in the future.
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Affiliation(s)
- Malin Rex
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Affective Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Thomas Brezicka
- Department for Quality and Patient Safety, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eric Carlström
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Margda Waern
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Psychosis Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lilas Ali
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Affective Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
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Wyder M, Ray MK, Roennfeldt H, Daly M, Crompton D. How health care systems let our patients down: a systematic review into suicide deaths. Int J Qual Health Care 2021; 32:285-291. [PMID: 32484207 DOI: 10.1093/intqhc/mzaa011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/26/2019] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To synthesize the literature in relation to findings of system errors through reviews of suicide deaths in the public mental health system. DATA SOURCES A systematic narrative meta-synthesis using the PRISMA methodology was conducted. STUDY SELECTION All English language articles published between 2000 and 2017 that reported on system errors identified through reviews of suicide deaths were included. Articles that reported on patient factors, contact with General Practitioners or individual cases were excluded. DATA EXTRACTION Results were extracted and summarized. An overarching coding framework was developed inductively. This coding framework was reapplied to the full data set. RESULTS OF DATA SYNTHESIS Fourteen peer reviewed publications were identified. Nine focussed on suicide deaths that occurred in hospital or psychiatric inpatient units. Five studies focussed on suicide deaths while being treated in the community. Vulnerabilities were identified throughout the patient's journey (i.e. point of entry, transitioning between teams, and point of exit with the service) and centred on information gathering (i.e. inadequate and incomplete risk assessments or lack of family involvement) and information flow (i.e. transitions between different teams). Beyond enhancing policy, guidelines, documentation and regular training for frontline staff there were very limited suggestions as to how systems can make it easier for staff to support their patients. CONCLUSIONS There are currently limited studies that have investigated learnings and recommendations. Identifying critical vulnerabilities in systems and to be proactive about these could be one way to develop a highly reliable mental health care system.
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Affiliation(s)
- Marianne Wyder
- Metro South Health and Hospital Service.,Menzies Health Institute Queensland, Griffith University
| | | | - Helena Roennfeldt
- Menzies Health Institute Queensland, Griffith University.,Centre for Psychiatric Nursing, University of Melbourne, School of Health Sciences
| | - Michael Daly
- Metro South Health and Hospital Service.,Queensland university of Technology
| | - David Crompton
- Metro South Health and Hospital Service.,Menzies Health Institute Queensland, Griffith University
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Turner K, Stapelberg NJ, Sveticic J, Dekker SW. Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework. Aust N Z J Psychiatry 2020; 54:571-581. [PMID: 32383403 DOI: 10.1177/0004867420918659] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians' experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. METHOD We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. RESULTS An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. CONCLUSIONS The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent 'inconvenient truths' that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture-based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.
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Affiliation(s)
- Kathryn Turner
- Mental Health and Specialist Services, Gold Coast Hospital and Health Services, Southport, QLD, Australia
| | - Nicolas Jc Stapelberg
- Mental Health and Specialist Services, Gold Coast Hospital and Health Services, Southport, QLD, Australia.,Faculty of Health Sciences & Medicine, Bond University, Robina, QLD, Australia
| | - Jerneja Sveticic
- Mental Health and Specialist Services, Gold Coast Hospital and Health Services, Southport, QLD, Australia
| | - Sidney Wa Dekker
- School of Humanities, Languages and Social Science, Griffith University, Nathan, QLD, Australia
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Bouwman R, de Graaff B, de Beurs D, van de Bovenkamp H, Leistikow I, Friele R. Involving Patients and Families in the Analysis of Suicides, Suicide Attempts, and Other Sentinel Events in Mental Healthcare: A Qualitative Study in The Netherlands. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1104. [PMID: 29843464 PMCID: PMC6025554 DOI: 10.3390/ijerph15061104] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 05/16/2018] [Accepted: 05/24/2018] [Indexed: 11/16/2022]
Abstract
Involving patients and families in mental healthcare is becoming more commonplace, but little is known about how they are involved in the aftermath of serious adverse events related to quality of care (sentinel events, including suicides). This study explores the role patients and families have in formal processes after sentinel events in Dutch mental healthcare. We analyzed the existing policies of 15 healthcare organizations and spoke with 35 stakeholders including patients, families, their counselors, the national regulator, and professionals. Respondents argue that involving patients and families is valuable to help deal with the event emotionally, provide additional information, and prevent escalation. Results indicate that involving patients and families is only described in sentinel event policies to a limited extent. In practice, involvement consists mostly of providing aftercare and sharing information about the event by providers. Complexities such as privacy concerns and involuntary admissions are said to hinder involvement. Respondents also emphasize that involvement should not be obligatory and stress the need for patients and families to be involved throughout the process of treatment. There is no one-size-fits-all strategy for involving patients and families after sentinel events. The first step seems to be early involvement during treatment process itself.
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Affiliation(s)
- Renée Bouwman
- NIVEL, P.O. Box 1568, 3500 BN Utrecht, The Netherlands.
| | - Bert de Graaff
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. box 1738, 3000 DR Rotterdam, The Netherlands.
| | | | - Hester van de Bovenkamp
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. box 1738, 3000 DR Rotterdam, The Netherlands.
| | - Ian Leistikow
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. box 1738, 3000 DR Rotterdam, The Netherlands.
- Dutch Healthcare and Youth Inspectorate, 3521 AZ Utrecht, The Netherlands.
| | - Roland Friele
- NIVEL, P.O. Box 1568, 3500 BN Utrecht, The Netherlands.
- TRANZO (Scientific Centre for Care and Welfare), Faculty of Social and Behavioural Sciences, Tilburg University, 5037 DB Tilburg, The Netherlands.
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Gillies D, Chicop D, O'Halloran P. Root Cause Analyses of Suicides of Mental Health Clients: Identifying Systematic Processes and Service-Level Prevention Strategies. CRISIS 2016; 36:316-24. [PMID: 26502781 DOI: 10.1027/0227-5910/a000328] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The ability to predict imminent risk of suicide is limited, particularly among mental health clients. Root cause analysis (RCA) can be used by health services to identify service-wide approaches to suicide prevention. AIMS To (a) develop a standardized taxonomy for RCAs; (b) to quantitate service-related factors associated with suicides; and (c) to identify service-related suicide prevention strategies. METHOD The RCAs of all people who died by suicide within 1 week of contact with the mental health service over 5 years were thematically analyzed using a data collection tool. RESULTS Data were derived from RCAs of all 64 people who died by suicide between 2008 and 2012. Major themes were categorized as individual, situational, and care-related factors. The most common factor was that clients had recently denied suicidality. Reliance on carers, recent changes in medication, communication problems, and problems in follow-through were also commonly identified. CONCLUSION Given the difficulty in predicting suicide in people whose expressions of suicidal ideation change so rapidly, services may consider the use of strategies aimed at improving the individual, stressor, support, and care factors identified in this study.
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Affiliation(s)
- Donna Gillies
- 1 Mental Health Services, Western Sydney Local Health District, Cumberland Hospital, Parramatta CBD, NSW, Australia
| | - David Chicop
- 1 Mental Health Services, Western Sydney Local Health District, Cumberland Hospital, Parramatta CBD, NSW, Australia
| | - Paul O'Halloran
- 1 Mental Health Services, Western Sydney Local Health District, Cumberland Hospital, Parramatta CBD, NSW, Australia
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O'Connor N, Hunt GE, O'Hara-Aarons M, Hall A, Snars J, Storm V, Lambert T. The Sydney Mental Health Client Mortality Audit: what does it tell us and what are we to do? Australas Psychiatry 2014; 22:154-9. [PMID: 24449531 DOI: 10.1177/1039856213519690] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To examine the characteristics of those mental health clients of an Australian metropolitan health service who died during a 6 year period, 2005 - 2010. METHODS The medical records, and where available, coronial post-mortem examinations were audited for 109 people with schizophrenia who died while they were clients of the mental health service. RESULTS The mean age of death for men was 45 years and for women, 47 years, compared to the general population's male and female life expectancy of 79 and 84 years, respectively. About one-half of the deaths were due to suicide (n = 55), followed by natural causes (n = 42; 39%), undetermined causes (n = 7), and accidents or acts of violence (n = 5). Smoking rates, diagnosed diabetes and hypertension were higher in the group that died from natural causes. Morbid obesity (body mass index (BMI) > 35 kg/m(2)) rates were higher in the group that died of natural causes (38%), compared with the suicide group (5%). CONCLUSIONS While suicide accounts for the majority of those dying prematurely in this study cohort, it appears that for those who survive the risk of suicide in the earlier period of a chronic psychotic illness, there is yet another threat to life expectancy: death from preventable cardiorespiratory disorders, due to a poor lifestyle and social deprivation.
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Affiliation(s)
- Nick O'Connor
- Clinical Director, North Shore Ryde Mental Health Service, St Leonards, NSW, and; Clinical Senior Lecturer, Discipline of Psychiatry, University of Sydney, Sydney, NSW, Australia
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