A 37-year-old man with a history of bipolar disorder is brought to the emergency department by family members after they prevented him from going to a gun range, where he had planned to shoot himself. On admission to the psychiatric unit, the patient reports being very depressed about breaking up with his girlfriend. In addition, she has recently posted photos of herself with her new boyfriend on social media. Since then, the patient has felt worthless and hopeless, believing that his life is not worth living. On his third day in the hospital he is taken off 1-to-1 constant observation and changed to 30-minute checks. That evening, he asks to speak with his former girlfriend by phone. Following the phone call, the patient does not come out for dinner and is not seen in his room. He is found hanging from a sheet fastened as a noose around the hinge of the bathroom door. He is unresponsive and appears pale. A staff member begins cardiopulmonary resuscitation while awaiting the rapid response team's arrival. Despite resuscitative measures, the patient remains unresponsive and dies. In responding to this incident, which of the following is the most appropriate next step for the hospital to prevent such occurrences in the future?

Question

A 37-year-old man with a history of bipolar disorder is brought to the emergency department by family members after they prevented him from going to a gun range, where he had planned to shoot himself.  On admission to the psychiatric unit, the patient reports being very depressed about breaking up with his girlfriend.  In addition, she has recently posted photos of herself with her new boyfriend on social media.  Since then, the patient has felt worthless and hopeless, believing that his life is not worth living.  On his third day in the hospital he is taken off 1-to-1 constant observation and changed to 30-minute checks.  That evening, he asks to speak with his former girlfriend by phone.  Following the phone call, the patient does not come out for dinner and is not seen in his room.  He is found hanging from a sheet fastened as a noose around the hinge of the bathroom door.  He is unresponsive and appears pale.  A staff member begins cardiopulmonary resuscitation while awaiting the rapid response team's arrival.  Despite resuscitative measures, the patient remains unresponsive and dies.  In responding to this incident, which of the following is the most appropriate next step for the hospital to prevent such occurrences in the future?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1f8_efab_8f63_470d115efb82_MD0005_00 Suicide inside a hospital setting is considered a sentinel event (ie, an unexpected occurrence involving actual or risk of death or serious injury) that requires investigation to determine whether the event could have been prevented, and if there are measures that can be taken to prevent future occurrences. Rather than jumping to conclusions and making reactive changes, the first step is to perform a root cause analysis. This is a quality improvement tool used to identify how and why an undesirable outcome occurred and to recommend corrective measures to prevent future occurrences. The initial phase involves collecting all relevant data and developing a causal factor flow chart. This allows for the identification of root causes or underlying deficiencies that could have led to the sentinel event. In this case, determining why the patient was taken off constant observation status would be a first step (eg, was this based on clinical judgment, the hospital being short-staffed, other high-acuity patients requiring more attention). Other possible contributing factors (eg, time taken to find the patient, adequacy of staff cardiopulmonary resuscitation training) can then be systematically analyzed, and recommendations (eg, increase staffing, standardize criteria for change in observational status) made to prevent future occurrences. (Choices B, C, D, and E) It is premature to implement these changes before gathering information and identifying root causes. Improving rapid response arrival time, increasing staff training, removing door hinges, and supervising patient phone calls can all be helpful measures. However, the root causes of the event must be determined prior to jumping to conclusions about what changes should be made. Educational objective: When unexpected serious outcomes (ie, sentinel events) occur, the first step is to perform a root cause analysis that collects all relevant data and identifies the underlying causes. Once the root causes are identified, targeted improvement measures can be implemented and monitored. References: A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers. (http://www.ncbi.nlm.nih.gov/pubmed/23367650) Analysis of errors in histology by root cause analysis: a pilot study. (http://www.ncbi.nlm.nih.gov/pubmed/24396989) The nature and causes of unintended events reported at ten emergency departments. (http://www.ncbi.nlm.nih.gov/pubmed/19765275)

A 37-Year-Old Man with a History of Bipolar Disorder Is