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Volumn 37, Issue 1, 2009, Pages 15-24

Reducing inpatient suicide risk: Using human factors analysis to improve observation practices

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL PRACTICE; CLINICAL TRIAL; HEALTH CARE SYSTEM; HOSPITAL PATIENT; HUMAN; MEDICAL ERROR; MEDICAL PRACTICE; MULTICENTER STUDY; OBSERVATIONAL STUDY; PATIENT ASSESSMENT; QUALITY CONTROL; REVIEW; RISK REDUCTION; SUICIDAL BEHAVIOR; COMPUTER PROGRAM; HEALTH CARE QUALITY; MENTAL DISEASE; MENTAL HOSPITAL; METHODOLOGY; NOTE; NURSING; OBSERVATION; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PSYCHOLOGICAL ASPECT; RISK MANAGEMENT; STANDARD; STATISTICS; SUICIDE; UNITED STATES;

EID: 66149140218     PISSN: 10936793     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review
Times cited : (41)

References (53)
  • 2
    • 67649325425 scopus 로고    scopus 로고
    • Joint Commission: Sentinel event statistics-June 30, 2008. Available at: http://www.jointcommission.org/NR/rdonlyres/ 24lCD6F3-6EF0-4E9C-90AD- 7FEAE5EDCEA5/0/SE-Stats-06-08.pdf. Accessed on October 1, 2008
    • Joint Commission: Sentinel event statistics-June 30, 2008. Available at: http://www.jointcommission.org/NR/rdonlyres/ 24lCD6F3-6EF0-4E9C-90AD- 7FEAE5EDCEA5/0/SE-Stats-06-08.pdf. Accessed on October 1, 2008
  • 3
    • 25844446678 scopus 로고    scopus 로고
    • The dynamics between structure and flexibility in constant observation of psychiatric inpatients with suicidal ideation
    • Vrale GB, Steen E: The dynamics between structure and flexibility in constant observation of psychiatric inpatients with suicidal ideation. J Psychiatr Ment Health Nurs 12:513-18, 2005
    • (2005) J Psychiatr Ment Health Nurs , vol.12 , pp. 513-518
    • Vrale, G.B.1    Steen, E.2
  • 4
    • 22544453598 scopus 로고    scopus 로고
    • Constant or special observations of inpatients presenting a risk of aggression or violence: Nurses' perceptions of the rules of engagement
    • Mackay I, Paterson B, Cassells C: Constant or special observations of inpatients presenting a risk of aggression or violence: Nurses' perceptions of the rules of engagement. J Psychiatr Ment Health Nurs 12:464-71, 2005
    • (2005) J Psychiatr Ment Health Nurs , vol.12 , pp. 464-471
    • Mackay, I.1    Paterson, B.2    Cassells, C.3
  • 5
    • 0036779524 scopus 로고    scopus 로고
    • Considering the care of the suicidal client and the case for 'engagement and inspiring hope' or 'observations'
    • Cutcliffe JR, Barker P: Considering the care of the suicidal client and the case for 'engagement and inspiring hope' or 'observations'. J Psychiatr Ment Health Nurs 9:611-21, 2002
    • (2002) J Psychiatr Ment Health Nurs , vol.9 , pp. 611-621
    • Cutcliffe, J.R.1    Barker, P.2
  • 7
    • 0032856675 scopus 로고    scopus 로고
    • The American Society of Anesthesiologists Closed Claims Project: What have we learned, how has it affected practice, and how will it affect practice in the future?
    • Cheney FW: The American Society of Anesthesiologists Closed Claims Project: what have we learned, how has it affected practice, and how will it affect practice in the future? Anesthesiology 91: 552-6,1999
    • (1999) Anesthesiology , vol.91 , pp. 552-556
    • Cheney, F.W.1
  • 8
    • 84944359105 scopus 로고
    • Standards for patient monitoring during anesthesia at Harvard Medical School
    • Eichhorn JH, Cooper JB, Cullen DJ, et al.: Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA 256:1017-20, 1986
    • (1986) JAMA , vol.256 , pp. 1017-1020
    • Eichhorn, J.H.1    Cooper, J.B.2    Cullen, D.J.3
  • 9
    • 84870424305 scopus 로고    scopus 로고
    • Available at:, Accessed April 13, 2008
    • American Society of Anesthesiologists: Patient safety. Available at: http://www.asahq.org/safety.htm. Accessed April 13, 2008
    • Patient safety
  • 10
    • 33646402314 scopus 로고    scopus 로고
    • The impact of intraoperative monitoring on patient safety
    • Mayfield JB: The impact of intraoperative monitoring on patient safety. Anesthesiol Clin 24:407-17, 2006
    • (2006) Anesthesiol Clin , vol.24 , pp. 407-417
    • Mayfield, J.B.1
  • 11
    • 67649355414 scopus 로고    scopus 로고
    • Joint Commission on Accreditation of Healthcare Organizations: Health care at the crossroads: strategies for improving the medical liability system and preventing patient injury. Available at: http:// www.jointcommission.org/NR/ rdonlyres/167DD821-A395-48 FD-87F9-6AB12BCACB0F/0/Medical-Liability.pdf. Accessed April 13, 2008
    • Joint Commission on Accreditation of Healthcare Organizations: Health care at the crossroads: strategies for improving the medical liability system and preventing patient injury. Available at: http:// www.jointcommission.org/NR/ rdonlyres/167DD821-A395-48 FD-87F9-6AB12BCACB0F/0/Medical-Liability.pdf. Accessed April 13, 2008
  • 12
    • 5644300386 scopus 로고    scopus 로고
    • Eliminating catheter-related bloodstream infections in the intensive care unit
    • Berenholtz SM, Pronovost PJ, Lipsett PA, et al.: Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 32:2014-20, 2004
    • (2004) Crit Care Med , vol.32 , pp. 2014-2020
    • Berenholtz, S.M.1    Pronovost, P.J.2    Lipsett, P.A.3
  • 13
    • 33845880922 scopus 로고    scopus 로고
    • An intervention to decrease catheter-related bloodstream infections in the ICU
    • Pronovost P, Needham D, Berenholtz S, et al.: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 355:2725-32, 2006
    • (2006) N Engl J Med , vol.355 , pp. 2725-2732
    • Pronovost, P.1    Needham, D.2    Berenholtz, S.3
  • 15
    • 67649325424 scopus 로고    scopus 로고
    • Louis Harris and Associates: National patient safety foundation at the AMA: public opinion of patient safety issues research findings. Available at: http://www.npsf.Org/pdf/r/1997survey.pdf. Accessed April 17,2008
    • Louis Harris and Associates: National patient safety foundation at the AMA: public opinion of patient safety issues research findings. Available at: http://www.npsf.Org/pdf/r/1997survey.pdf. Accessed April 17,2008
  • 16
    • 0028097184 scopus 로고
    • Error in medicine
    • Leape LL: Error in medicine. JAMA 272:1851-7, 1994
    • (1994) JAMA , vol.272 , pp. 1851-1857
    • Leape, L.L.1
  • 17
    • 0031196232 scopus 로고    scopus 로고
    • A systems analysis approach to medical error
    • Leape LL: A systems analysis approach to medical error. J Eval Clin Pract 3:213-22, 1997
    • (1997) J Eval Clin Pract , vol.3 , pp. 213-222
    • Leape, L.L.1
  • 18
    • 0035232297 scopus 로고    scopus 로고
    • Foreword: Preventing medical accidents-is "systems analysis" the answer?
    • Leape LL: Foreword: preventing medical accidents-is "systems analysis" the answer? Am J Law Med 27:145-8, 2001
    • (2001) Am J Law Med , vol.27 , pp. 145-148
    • Leape, L.L.1
  • 20
    • 0004223940 scopus 로고
    • Cambridge, MA: Cambridge University Press
    • Reason J: Human Error. Cambridge, MA: Cambridge University Press, 1990
    • (1990) Human Error
    • Reason, J.1
  • 21
    • 84869295876 scopus 로고    scopus 로고
    • Patient Protection Act of 1998. H.R. 4259 § 5004(b) Protection for certain information developed to reduce mortality or morbidity or for improving patient care and safety, 1998. Available at http://cltg.org/cltg/privacy/hr4250. html. Accessed November 8, 2008
    • Patient Protection Act of 1998. H.R. 4259 § 5004(b) Protection for certain information developed to reduce mortality or morbidity or for improving patient care and safety, 1998. Available at http://cltg.org/cltg/privacy/hr4250. html. Accessed November 8, 2008
  • 22
    • 34247502048 scopus 로고    scopus 로고
    • Implications for the peer review process
    • Trueblood KV: Implications for the peer review process. J Am Acad Psychiatry Law 35:125128, 2007
    • (2007) J Am Acad Psychiatry Law , vol.35 , pp. 125128
    • Trueblood, K.V.1
  • 23
    • 34547611678 scopus 로고    scopus 로고
    • Joint Commission:, updated July 2007. Available at:, Accessed February 19, 2008
    • Joint Commission: Sentinel events policy and procedure, updated July 2007. Available at: http://www.jointcommission.org/NR/ rdonlyres/F84F9DC6-A5DA- 490F-A91F-A9FCE26347C4/0/ SE-chapter-july07.pdf. Accessed February 19, 2008
    • Sentinel events policy and procedure
  • 24
    • 0032491360 scopus 로고    scopus 로고
    • Inpatient suicides: Recommendations for prevention
    • Anonymous
    • Anonymous: Inpatient suicides: recommendations for prevention. Sentinel Event Alert 7:1-2, 1998
    • (1998) Sentinel Event Alert , vol.7 , pp. 1-2
  • 25
    • 67649323117 scopus 로고    scopus 로고
    • Joint Commission: Sentinel event statistics-June 30, 2008: sentinel event trends reported by year. Available at: http://www.jomt-commission.org/NR/ rdonlyres/67297896-4E 16-4BB7-BF0F-5DA4A87B02F2/0/se-stats-trends-year.pdf. Accessed September 4, 2008
    • Joint Commission: Sentinel event statistics-June 30, 2008: sentinel event trends reported by year. Available at: http://www.jomt-commission.org/NR/ rdonlyres/67297896-4E 16-4BB7-BF0F-5DA4A87B02F2/0/se-stats-trends-year.pdf. Accessed September 4, 2008
  • 26
    • 67649374442 scopus 로고    scopus 로고
    • Anonymous: Preventing suicide, in Front Line of Defense: The Role of Nurses in Preventing Sentinel Events (ed 2). Edited by Pourch6 RA Jt. Oakbrook Terrace, IL: Joint Commission Resources, 2007, pp 113-28
    • Anonymous: Preventing suicide, in Front Line of Defense: The Role of Nurses in Preventing Sentinel Events (ed 2). Edited by Pourch6 RA Jt. Oakbrook Terrace, IL: Joint Commission Resources, 2007, pp 113-28
  • 27
    • 67649357691 scopus 로고    scopus 로고
    • Jacobs DG, Baldessarini RJ, Conwell Y, et al.: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160:1-60, 2003. Available at: http://www. psychiatryonline.com/ pracGuide/loadGuidelinePdf.aspx?file= SuicidalBehavior-05-15-06. Accessed May 10, 2008
    • Jacobs DG, Baldessarini RJ, Conwell Y, et al.: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160:1-60, 2003. Available at: http://www. psychiatryonline.com/ pracGuide/loadGuidelinePdf.aspx?file= SuicidalBehavior-05-15-06. Accessed May 10, 2008
  • 28
    • 0033769240 scopus 로고    scopus 로고
    • The Clarke Institute experience with completed suicide: 1966 to 1997
    • Martin BA: The Clarke Institute experience with completed suicide: 1966 to 1997. Can J Psychiatry 45:630-8, 2000
    • (2000) Can J Psychiatry , vol.45 , pp. 630-638
    • Martin, B.A.1
  • 29
    • 0034221588 scopus 로고    scopus 로고
    • Suicide and self-harm in in-patient psychiatric units: A study of nursing issues in 31 cases
    • Gournay K, Bowers L: Suicide and self-harm in in-patient psychiatric units: A study of nursing issues in 31 cases. J Adv Nurs 32:124-31,2000
    • (2000) J Adv Nurs , vol.32 , pp. 124-131
    • Gournay, K.1    Bowers, L.2
  • 31
    • 20444483211 scopus 로고    scopus 로고
    • A case-control study of 92 cases of in-patient suicides
    • Dong JY, Ho TP, Kan CK: A case-control study of 92 cases of in-patient suicides. J Affect Disord 87:91-9, 2005
    • (2005) J Affect Disord , vol.87 , pp. 91-99
    • Dong, J.Y.1    Ho, T.P.2    Kan, C.K.3
  • 32
    • 31644445190 scopus 로고    scopus 로고
    • Suicide in mental health in-patients and within 3 months of discharge: National clinical survey
    • Meehan J, Kapur N, Hunt IM, et al.: Suicide in mental health in-patients and within 3 months of discharge: national clinical survey. Br J Psychiatry 188:129-34, 2006
    • (2006) Br J Psychiatry , vol.188 , pp. 129-134
    • Meehan, J.1    Kapur, N.2    Hunt, I.M.3
  • 34
    • 0028306143 scopus 로고
    • Inpatient standards of care and the suicidal patient, part II: An integration with clinical risk management
    • Silverman MM, Berman AL, Bongar B, et al.: Inpatient standards of care and the suicidal patient, part II: an integration with clinical risk management. Suicide Life Threat Behav 24:152-69, 1994
    • (1994) Suicide Life Threat Behav , vol.24 , pp. 152-169
    • Silverman, M.M.1    Berman, A.L.2    Bongar, B.3
  • 35
    • 0020759339 scopus 로고
    • The development of suicide precautions for an inpatient psychiatric unit
    • Busteed EL, Johnstone C: The development of suicide precautions for an inpatient psychiatric unit. J Psychosoc Nurs Ment Health Serv 21:15-19, 1983
    • (1983) J Psychosoc Nurs Ment Health Serv , vol.21 , pp. 15-19
    • Busteed, E.L.1    Johnstone, C.2
  • 36
    • 0034322118 scopus 로고    scopus 로고
    • Discourse analysis of an 'observation levels' nursing policy
    • Horsfall J, Cleary M: Discourse analysis of an 'observation levels' nursing policy. J Adv Nurs 32:1291-7, 2000
    • (2000) J Adv Nurs , vol.32 , pp. 1291-1297
    • Horsfall, J.1    Cleary, M.2
  • 37
    • 3042676389 scopus 로고    scopus 로고
    • Close-observation areas in acute psychiatric units: A literature review
    • O'Brien L, Cole R: Close-observation areas in acute psychiatric units: a literature review. Int J Ment Health Nurs 12:165-76, 2003
    • (2003) Int J Ment Health Nurs , vol.12 , pp. 165-176
    • O'Brien, L.1    Cole, R.2
  • 38
    • 0025161879 scopus 로고
    • Continuous observation for psychiatric inpatients: A critical evaluation
    • Shugar G, Rehaluk R: Continuous observation for psychiatric inpatients: a critical evaluation. Compr Psychiatry 31:48-55, 1990
    • (1990) Compr Psychiatry , vol.31 , pp. 48-55
    • Shugar, G.1    Rehaluk, R.2
  • 39
    • 0029650755 scopus 로고    scopus 로고
    • Supervising suicidal patients within a hospital setting
    • Thomas B: Supervising suicidal patients within a hospital setting. BrJ Nurs 4:212-15
    • BrJ Nurs , vol.4 , pp. 212-215
    • Thomas, B.1
  • 40
    • 0035322893 scopus 로고    scopus 로고
    • The use of special observations: An audit within a psychiatric unit
    • Neilson P, Brennan W: The use of special observations: an audit within a psychiatric unit. J Psychiatr Ment Health Nurs 8:147- 55, 2001
    • (2001) J Psychiatr Ment Health Nurs , vol.8 , pp. 147-155
    • Neilson, P.1    Brennan, W.2
  • 42
    • 0029298985 scopus 로고
    • Out of the shadows: A study of the special observation of suicidal psychiatric inpatients
    • Duffy D: Out of the shadows: a study of the special observation of suicidal psychiatric inpatients. J Adv Nurs 21:944-50, 1995
    • (1995) J Adv Nurs , vol.21 , pp. 944-950
    • Duffy, D.1
  • 43
    • 0034241460 scopus 로고    scopus 로고
    • Suicide and self-harm in inpatient psychiatric units: A national survey of observation policies
    • Bowers L, Gournay K, Duffy D: Suicide and self-harm in inpatient psychiatric units: A national survey of observation policies. J Adv Nurs 32:437-44, 2000
    • (2000) J Adv Nurs , vol.32 , pp. 437-444
    • Bowers, L.1    Gournay, K.2    Duffy, D.3
  • 44
    • 1642566777 scopus 로고    scopus 로고
    • Is there a relationship between risk assessment and observation level?
    • Kettles AM, Moir E, Woods P, et al.: Is there a relationship between risk assessment and observation level? J Psychiatr Ment Health Nurs 11:156-64, 2004
    • (2004) J Psychiatr Ment Health Nurs , vol.11 , pp. 156-164
    • Kettles, A.M.1    Moir, E.2    Woods, P.3
  • 45
    • 0036617891 scopus 로고    scopus 로고
    • Formal observations and engagement: A discussion paper
    • Bowles N, Dodds P, Hackney D, et al.: Formal observations and engagement: a discussion paper. J Psychiatr Ment Health Nurs 9:255-60, 2002
    • (2002) J Psychiatr Ment Health Nurs , vol.9 , pp. 255-260
    • Bowles, N.1    Dodds, P.2    Hackney, D.3
  • 46
    • 0030577053 scopus 로고    scopus 로고
    • Special eyes
    • Lehane M: Special eyes. Nurs Stand 11:21, 1996
    • (1996) Nurs Stand , vol.11 , pp. 21
    • Lehane, M.1
  • 47
    • 67649333948 scopus 로고    scopus 로고
    • Doughty C (editor): Suicide prevention topic 9: what evidence is there about the use of seclusion or containment for patients presenting with suicidal behaviours at emergency departments, tertiary mental health services or inpatient units? NZHTA Report 2002. Available at: http://nzhta.chmeds.ac.nz/ publications/ topic9.pdf. Accessed February 10, 2008
    • Doughty C (editor): Suicide prevention topic 9: what evidence is there about the use of seclusion or containment for patients presenting with suicidal behaviours at emergency departments, tertiary mental health services or inpatient units? NZHTA Report 2002. Available at: http://nzhta.chmeds.ac.nz/ publications/ topic9.pdf. Accessed February 10, 2008
  • 48
    • 0035322912 scopus 로고    scopus 로고
    • Dismantling formal observation and refocus-ing nursing activity in acute inpatient psychiatry: A case study
    • Dodds P, Bowles N: Dismantling formal observation and refocus-ing nursing activity in acute inpatient psychiatry: a case study. J Psychiatr Ment Health Nursing 8:183-8, 2001
    • (2001) J Psychiatr Ment Health Nursing , vol.8 , pp. 183-188
    • Dodds, P.1    Bowles, N.2
  • 49
    • 0033070026 scopus 로고    scopus 로고
    • The process of constant observation: Perspectives of staff and suicidal patients
    • Fletcher RF: The process of constant observation: perspectives of staff and suicidal patients. J Psychiatr Ment Health Nurs 6:9-14, 1999
    • (1999) J Psychiatr Ment Health Nurs , vol.6 , pp. 9-14
    • Fletcher, R.F.1
  • 50
    • 6944236227 scopus 로고    scopus 로고
    • Mental health nursing practice in acute psychiatric close-observation areas
    • O'Brien L, Cole R: Mental health nursing practice in acute psychiatric close-observation areas. Int J Ment Health Nurs 13:89-99,2004
    • (2004) Int J Ment Health Nurs , vol.13 , pp. 89-99
    • O'Brien, L.1    Cole, R.2
  • 51
    • 77952966361 scopus 로고    scopus 로고
    • is done. Available at:, Accessed April 27, 2008
    • Smith DL: FMEA: preventing a failure before any harm is done. Available at: http://healthcare.isixsigma.com/library/content/ c040317a.asp?action=print. Accessed April 27, 2008
    • FMEA: Preventing a failure before any harm
    • Smith, D.L.1
  • 52
    • 18944399874 scopus 로고    scopus 로고
    • Available at:, Accessed April 27, 2008
    • Institute for Healthcare Improvement: Failure modes and effects analysis (FMEA). Available at: http://www.ihi.org/NR/rdonlyres/ 87CDA0El-8D46-4l4F-8577- BE230421lA54/972/Failure ModesandEffectsAnalysis-FMEA-l.pdf. Accessed April 27, 2008
    • Failure modes and effects analysis (FMEA)
  • 53
    • 18944399874 scopus 로고    scopus 로고
    • Available at:, Accessed May 11, 2008
    • Institute for Healthcare Improvement: Failure modes and effects analysis (FMEA) tool. Available at: http://www.ihi.org/ihi/work-space/tools/fmea/. Accessed May 11, 2008
    • Failure modes and effects analysis (FMEA) tool


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