Abstract
BackgroundThe objective of this study was to assess sentinel event analysis and relative factors in different mental healthcare settings. In addition, the occurrence of sentinel events in different hospital settings was compared and potential risk factors contributing to sentinel events identified.MethodsA total of 75 consecutive adult subjects were enrolled from 2 psychiatric units, 1 within a general hospital and 1 at a psychiatric hospital in southern Taiwan. A retrospective chart review of the psychiatric inpatients was conducted for patients that met the criteria for a sentinel event between July 2004 and May 2011. A comparison of the hospital settings was made and differences between suicidal and non-suicidal sentinel events studied.ResultsPsychiatric patients that received general hospital psychiatric services (1) appeared to experience a sentinel event soon after admission, (2) the time between the sentinel event occurrence and patient death was shorter, (3) there was a higher probability of potential medical illness than among inpatients treated at a specialized psychiatric hospital, (4) the sentinel event subjects that committed suicide were younger, had a shorter hospital stay, shorter time to occurrence of the sentinel event followed by an unexpected death than the non-suicidal group, and (5) a younger age, higher education level, previous suicide attempt and family psychiatric history were important predictors of suicide among psychiatric inpatients.ConclusionsThe results of this study suggest that psychiatric inpatients treated at a general hospital require careful examination for potential physical illness and greater efforts to prevent suicide. A younger age, higher education level, history of a previous suicide attempt and family psychiatric history are additional risk factors for suicide among these patients.
Highlights
In order to improve patient safety, there have been significant changes in the way health services are provided in the hospital setting [1]
A total of 75 sentinel events were reported from the 2 hospital settings studied; 52 patients were from a psychiatric unit within a general hospital and 23 patients were from a psychiatric hospital
The mean occurrence time of a sentinel event followed by an unexpected death for psychiatric inpatients from the general hospital was 5.5 ± 14.4 h, and for inpatients from the psychiatric hospital was 21.9 ± 80.9 h
Summary
In order to improve patient safety, there have been significant changes in the way health services are provided in the hospital setting [1]. The. Joint Commission on Accreditation of Healthcare Organizations (JCAHO, the Joint Commission) updated their definition of a sentinel event in 2007; the current definition is as follows: a sentinel event is an ‘unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof’. The phrase ‘or the risk thereof’ includes any variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called ‘sentinel’ because they signal the need for immediate investigation and response [2]. The objective of this study was to assess sentinel event analysis and relative factors in different mental healthcare settings. The occurrence of sentinel events in different hospital settings was compared and potential risk factors contributing to sentinel events identified
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