Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention

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.

[A cultural shift is needed to improve patient safety]

In a recently published thesis, we propose a cultural shift in the assessment of suicide as an incident of severe patient harm, from a focus on errors and an often speculative avoidability, to healthcare's ability of risk management over time. Patient safety work needs to change in line with the development of knowledge in patient safety. This means a cultural change in the view of patient safety, with a clearer focus on healthcare's abilities in risk management and learning. Legislation and regulations regarding healthcare and the supervisory authority need to support this cultural change in assessment and investigations of patient harm.  A shift from a focus on errors and deviations to quality and positive outcomes of care, proactive patient safety work, risk management, patient safety culture and management commitment is needed.

[Proactive work with patient safety in psychiatry, Patient safety in Real time in Psychiatry]

Traditionally, work with patient safety has mainly been focused on examining and learning from incidents retrospectively. Proactive methods to support and evaluate patient safety as work-as-done in real time are needed. Patient safety in Real time in Psychiatry (PiRiP), combining systematic reviews of inpatient records and interviews with inpatients and staff, can be such a method. We have evolved and tested this approach in psychiatric wards in Region Jönköping County and Region Västernorrland. We found that discussion and reflection with staff about the patients' views of care and treatment, observed strengths, risks and possibilities of improvement were of value to increase awareness and knowledge of how performance of daily work relates to patient safety. PiRiP adheres to the basic principles of patient safety as described in the national action plan for patient safety.

Health care utilisation two years prior to suicide in Sweden: a retrospective explorative study based on medical records

OBJECTIVE

Previous literature has suggested that identifying putative differences in health care seeking patterns before death by suicide depending on age and gender may facilitate more targeted suicide preventive approaches. The aim of this study is to map health care utilisation among individuals in the two years prior to suicide in Sweden in 2015 and to examine possible age and gender differences.

METHODS

Design: A retrospective explorative study with a medical record review covering the two years preceding suicide.

SETTING

All health care units located in 20 of Sweden's 21 regions.

PARTICIPANTS

All individuals residing in participating regions who died by suicide during 2015 (n = 949).

RESULTS

Almost 74% were in contact with a health care provider during the 3 months prior to suicide, and 60% within 4 weeks. Overall health care utilisation during the last month of life did not differ between age groups. However, a higher proportion of younger individuals (< 65 years) were in contact with psychiatric services, and a higher proportion of older individuals (≥ 65 years) were in contact with primary and specialised somatic health care. The proportion of women with any type of health care contact during the observation period was larger than the corresponding proportion of men, although no gender difference was found among primary and specialised somatic health care users within four weeks and three months respectively prior to suicide.

CONCLUSION

Care utilisation before suicide varied by gender and age. Female suicide decedents seem to utilise health care to a larger extent than male decedents in the two years preceding death, except for the non-psychiatric services in closer proximity to death. Older adults seem to predominantly use non-psychiatric services, while younger individuals seek psychiatric services to a larger extent.

Utilization of psychiatric services prior to suicide- a retrospective comparison of users with and without previous suicide attempts

INTRODUCTION

The aim was to investigate psychiatric health care utilization two years before death by suicide among individuals with previous suicide attempts (PSA) compared with those without (NSA).

METHOD

A retrospective population-based cohort study was conducted including 484 individuals who died by suicide in Sweden in 2015 and were in contact with psychiatric services within the two years preceding death, identified through the Cause of Death register. Data on psychiatric health care two years before death, including suicide attempts according to notes in the medical record was used. Associations between having at least one PSA vs. NSA and health care utilization were estimated as odds ratios (OR) with 95% confidence intervals (CI) by logistic regression analyses.

RESULTS

Of the 484 individuals included, 51% had PSA. Those with PSA were more likely than NSA to have received a psychiatric diagnosis [OR 1.96 (CI 95% 1.17-3.30)], to have ongoing psychotropic medication [OR 1.96 (CI 95% 1.15-3.36)] and to have been absent from appointments during the last three months [1.97 (1.25-3.13)]. In addition, elevated suicide risk was more often noted in the psychiatric case records of those with a PSA than those without [OR 2.17 (CI 95% 1.24-3.79)].

CONCLUSION

The results underline the importance of improved suicide risk assessment as well as thorough diagnostic assessment and when indicated, psychiatric treatment as suicide preventive interventions regardless of PSA. Furthermore, the larger proportion of absence from appointments in individuals with PSA may indicate a need of improved alliance between psychiatric care providers and individuals with PSA.HIGHLIGHTSBeing assessed with elevated suicide risk was more common among those with previous attempt/s (PSA).One-fifth of all with no previous attempt (NSA) had no psychiatric diagnosis, compared to one in ten in those with PSA.Receiving psychotropic medication was more common among those with PSA.

Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective

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.

[Patient safety in real time at covid-19 units in Region Jönköping County]

The adaptation of the healthcare needed in the covid-19 pandemic poses challenges to patient safety. Proactive patient safety work must continue even under conditions such as a pandemic. Methods are needed that assess and support patient safety as the work is carried out. Patient safety in real time appears to be such a useful method in which patient record review to identify patient harm is combined with interviews with patients and healthcare staff. The method was used in wards and intensive care units (ICU) for covid-19 patients in Region Jönköping County. Patient harm was found in ICU care. Patients were overall satisfied with the care, and in the interviews with healthcare staff areas for improvement were identified. Valid indicators for patient record review to evaluate patient harm in covid-19 need to be developed. To judge if patient harm in care of a Covid-19 is avoidable or not is difficult since the level of knowledge and treatment principles in the disease develops very fast.