Reducing adverse events has become a central focus of the health care system over the last two decades both within and outside of the VA. However, patients with mental disorders have been excluded from the major research in this field. Although we have good reason to believe that adverse events in psychiatric inpatient care are important sources of preventable morbidity and mortality, we do not know the magnitude of the problem because the basic epidemiology of patient safety in inpatient psychiatry has never been examined.
As the first rigorous epidemiologic study to document the full range of patient safety events that occur in inpatient psychiatric units in the VHA, we seek to establish an additional evidence base that will increase understanding, promote safety, and improve quality of care for persons with serious mental illness.
The objectives of this study were to 1) Assess the incidence and nature of adverse events that occur within VA medical center inpatient psychiatric units and identify patient characteristics associated with these events; and 2) Use qualitative methods to understand the mechanisms by which patient, provider, and organizational factors improve or impede patient safety in the VHA system.
The study drew from a national sample of 40 VA psychiatric units to characterize 8,005 hospitalizations by extracting detailed information from inpatient CPRS medical records utilizing a standardized adverse event abstraction tool. Using a manualized training protocol we developed, we trained 4 medical record administrators (MRA) and 9 physician reviewers to conduct the chart review. The MRA team screened records for the presence of a potential patient safety event and then our team of physician reviewers evaluated the charts that screened positive for a potential patient safety event to evaluate for patient harm, presence of error, and preventability. Finally, we conducted in-depth qualitative interviews with 20 key informants at 10 sites selectively sampled based on their bedsize.
Throughout the study period, we developed and implemented two manualized training programs for: 1) first-tier screening by medical record administrators (MRAs) to identify/flag potential patient safety events in inpatient psychiatry units; and 2) second-tier review of "flagged" charts by physician reviewers for more thorough clinical examination. After this extensive training, our team of 4 MRAs screened the medical records of 8005 discharges, over half of which were referred for physician review by our 9 trained physicians. Our preliminary analysis indicates that the most common types of events are: medication errors (including missed doses, delayed doses of more than 3 hours, and incorrect drug administration), adverse drug reactions (ADRs), falls, and patient assault that were identified in 11.5%, 3.7%, 2.4%, and 1% of the charts, respectively. Less common were events relating to patient self-harm or injury (.44%), patient assault (.93%), sexual contact (.11%), elopement (.20%), contraband (.65%), other non-drug adverse events (.14%), and other non-drug medical errors (.35%).
We have also completed 20 open-ended, semi-structured phone interviews with key nursing and physician staff (Nurse Managers and Medical Directors) at 10 VA inpatient psychiatric units. Interviews were conducted by four experienced interviewers, transcribed and entered into NVivo, then independently coded by two members of the study team. Initial findings identify factors that contributed to risk of patient injury, including: 1) patient-level factors (comorbid substance abuse and medical conditions, patient age); provider-level factors (lack of accountability and engagement, low staff morale); and system factors (bureaucracy, funding constraints). Together with the chart review data, these findings have important implications for improving patient safety for a vulnerable patient population.
This epidemiologic study is the first large-scale systematic examination of adverse events and medical errors in inpatient psychiatry at VA hospitals. In combination with the qualitative portion of the study, we have gained insight into the factors that contribute to or influence the extent to which adverse events and errors occur. Combined with detailed demographic and clinical information we collected, this will help us clarify which patient risk factors are most relevant for individuals treated in VA inpatient psychiatry and to identify the most relevant, high-priority interventions to mitigate these risk factors. These results will have important implications for policy-making, with the potential for improvements in care.
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