Patient Safety in Mental Health - Essay Example

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1742 words
Boston College
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Latest study indicates that a large number of mental health patients nowadays undergo treatment with the minimal incident by medical practitioners. However, some episodes still occur during a treatment process. Such events include slips, falls, and misdiagnosis by medical staff, among others. Since the latest outcry by the World Health Organization (WHO) to various health organizations around the world on the need to eliminate contributors of patient injury in mental health, many institutions have taken heed and have started working on such errors. The WHO stated that at least 80% of such incidences arise from medical mistakes, and therefore it is necessary for health organizations worldwide to develop and establish best practices for the safety of patients. The outcry calls for the development and establishment of incident reporting systems, as well as policies and measures to curb such incidences.

Incidents such as unintentional injuries and complications caused by healthcare personnel are some of the critical pointers of patient trauma in mental health institutions. Such indicators lead to patient injuries, disability, prolonged stays in the hospital, or even patient deaths. A study by a private Canadian research institute indicates that 7.6% of patients admitted to acute mental care hospitals in 2015 experienced at least one adverse incident, 37% of which were preventable. Many of the patient safety risk factors existing in the mental health institutions revolve around safety problems such as the use of seclusion and restraint, self-inflicted injuries, and suicide. In as much as risk management is concerned, research shows that there is still no precise information concerning the types of incidents and causes of adverse occurrences in the treatment of patients with mental health cases in the United States mental health care. Therefore, by creating a character profile of an anonymous patient, this paper aims at researching and identifying the need for mental health service user, existing mental health problems and today's situation of mental health. The study also identifies the solutions to meet the requirement and answers on how to solve the mental health problems

Patient Safety Incidents

While working on a med-tele floor, Donna Riemer, a certified traumatologist was asked to assist with a mentally ill patient who could not be controlled. The client had scores of self-inflicted injuries all over his body. According to the practitioners, they had tried everything they could to manage the patients. They had worked the use of seclusion and restraint but all in vain. Donna approached the patient who at that time was screaming, terrified of an unseen man in the corner of his room. The patient claimed that the man was there to kill him. Donna asked him if he wanted her to ask the man to leave and the person with a mental health condition said yes. She asked the man (practical man) rather firmly and sternly to go and warned him not to come back. She then asked the patient if she wanted her to hold his hand so that he could feel safe and he agreed. She did just that, and after a few minutes, the patient fell asleep. The staff was amazed by the outcome. They were thankful for my help. Later on, they learned a valuable lesson that engaging the patient in a talk and meeting his needs, even though unclear, proved to be of help in solving a sensitive issue.

A patient safety incident refers to an event, occurrence or circumstance which almost resulted or resulted in an uncalled for harm to the patient whereas an adverse event or incident relates to an incident which results in injury to a patient. Prejudice is an outcome that affected a patient's health negatively. We will use the above profile in identifying the customer need, that is, by analyzing the client's actions, emotions, thoughts, and motivations. Lastly, we will determine the potential solutions to the incidents.

Contributing Factors to Patient Safety Incidents

A study in non-health care settings has indicated that, in most incidences, no single factor contributes to an unintended failure such as a safety event. Safety incidents encompass a variety of multifaceted interaction between a set of parameters, including social and cultural factors, human behavior, hospital procedural weaknesses, as well as technological failure of the system. Therefore, understanding these factors is crucial in developing strategies to mitigate and prevent patient safety occurrences. Contributing factors to patient safety incidents can be classified in many ways. One common category is between the sole elements leading to patient safety events, that is, human and system errors.

In the past decades, the blame for patient safety incidences fell on individuals, but recently other factors have been taken into consideration. Such factors include patients engaging in harmful behaviors and clinical errors by the medical staff. Focusing on individual elements is seen as bias as it ignores the background on how the incident occurred. Therefore, apart from understanding the context by which the incident occurred, medical practitioners have the mandate to analyze system-level factors that might contribute to the events as well. This approach assists in extending the responsibility for responding to patient safety. While considering the character profile above, below are some of the factors that contribute to patient safety incidents.

Patient Factors

From the character profile above, it is evident that a mentally ill patient at risk from a specific unruly behavior is likely to be at higher risk for another unruly behavior. To be precise, the practice of harming oneself, aggression, absconding, and suicide is expected to occur in the same patient. While patients are accused of being aggressors of self-harm, management of many mental health organizations fail to recognize the efforts of the patients to avoid risky behaviors that cause harm to them. For Recent study indicates that psychiatric patients are actively involved in making their environment safer for themselves and others. They do this by avoiding risky behaviors, seeking surveillance and other safety interventions from personnel, and making their colleagues aware of their unruliness. These findings indicate the significance of thoroughly involving mental health care users in safety programs. Take for instance the case of Donna, whereby she decided to participate the deranged patient in the process eventually controlling the situation.

Also, in personal understanding factors that contribute to patient injury in mental health settings, it is essential for medical staff to consider the effects of psychiatric diagnosis. Psychiatric diagnosis interferes with the communication between patients and the staff involved. It also hurts the process of reporting patient safety incidents. Mentally ill patients are unlikely to seek out help if their situation worsens. Other symptoms of co-morbid substance abuse also put patients at risk for self-harm, aggression against staff or other patients. In acute cases, the patients may even resort to suicide. Mitigation procedures for such patients always involve administration of excessive doses of medication which makes it difficult to engage the victim in a proper communication thus putting their lives in danger.

Provider Factors

The study has indicated that mental health providers are significant contributors to patient injury in mental health care setting. In many instances, the staff has faced criticism for failing to handle aggression from the patients in a professional manner. Medical practitioners should know how to regulate their emotions, especially fear and anger towards patients as their behavior in handling the situation is likely to impact the rates of aggression, absconding, and self-harm. Research also mentions the demand of work environment as a contributing factor to self-inflicted harm. In a mental health setting, the number of visitors is limited thus exposing the clients to patient safety incidents. Research links patient safety incidents to poor communication between healthcare providers and patients, and the patients' families. Factors that contribute to the poor discussion in a mental health environment include heavy workload, unlicensed personnel, and interpersonal conflict, and this evident in the above profile. The staff was not able to deal with the situation probably because of inexperience, and only Donna could understand the need of the patient.

Organizational Factors

Research mentions systems not accompanied by directly observable symptoms such as human resources, admission and discharge procedures, recruitment and retention processes, as well as training programs as contributing factors to patient safety. In most cases, these systems are always beyond the control of the relevant providers of mental health care. However, these methods are mainly influenced by the policies and procedures of the organization. These systems if adequately coordinated will impact not only the rate of patient safety but also the frequency of reporting the incidents. Lack of harmonization within mental health setting and between mental health and general medical systems contributes mainly to patient safety incidents. Factors such as bed shortages, lack of proper communication, and shortages in staffing also contribute to patient safety incidents.

Also, the performance of the system as a whole, as well as admittance to various constituents of care across the organization also has an effect on patient safety in a mental health setting. Limited community resources such as staff housing and water also increase patient safety risks. Mental health facility located in a poor neighborhood or that characterized by high rate of substance abuse as well as violence will be likely to experience more patient safety incidents. Also, different treatment models of health care applied in the treatment of mental illness are likely to impact on the patient safety risk. For example, application of psychiatric consultation in the adverse incidents stretches the resources available in the emergency department. Therefore, in case of an emergency and the funds are depleted, the patient will be at higher risk of not getting proper medical attention. Thus, it is necessary to use the most convenient model to avoid such discrepancies. For example, triangulation of the patients by a separate staff reduces waiting time, use of retention and seclusion, while at the same time increasing the completion of mental health examinations.


In summary, one patient safety incident was used to guide a final review of patient safety in the mental health environment. Factors that are likely to expose psychological health patients to safety risks such as aggression, violence, self-inflicted injuries, seclusion, and retention, as well as suicide are discussed in this essay. Literature review unmasked several areas for future research to focus on, including research in mental health settings, specifically adults, and children as well as adolescents. Another area for future research is the emotional and psychological outcomes resulting from patient safety incidents. Lastly, there is the need for proper assessment and management of risks is necessary for reducing conflicts related patient safety in mental health.

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