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Reducing Inpatient Suicide Risk: Using Human Factors Analysis to Improve Observation Practices

Dr. Janofsky is Clinical Professor of Psychiatry, University of Maryland School of Medicine, and Associate Professor of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD. This article was adapted from the President's Address given at the 39th Annual Meeting of the American Academy of Psychiatry and the Law, Seattle, WA, October 23, 2008. Address correspondence to: Jeffrey S. Janofsky, MD, The Johns Hopkins Hospital, Meyer 4-181, 600 N. Wolfe Street, Baltimore, MD 21287. E-mail: jjanofsky{at}jhu.edu

In 1995, the Joint Commission began requiring that hospitals report reviewable sentinel events as a condition of maintaining accreditation. Since then, inpatient suicide has been the second most common sentinel event reported to the Joint Commission. The Joint Commission emphasizes the need for around-the-clock observation for inpatients assessed as at high risk for suicide. However, there is sparse literature on the observation of psychiatric patients and no systematic studies or recommendations for best practices. Medical errors can best be reduced by focusing on systems improvements rather than individual provider mistakes. The author describes how failure modes and effects analysis (FMEA) was used proactively by an inpatient psychiatric treatment team to improve psychiatric observation practices by identifying and correcting potential observation process failures. Collection and implementation of observation risk reduction strategies across health care systems is needed to identify best practices and to reduce inpatient suicides.

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