Adverse events in veterans affairs inpatient psychiatric units: Staff perspectives on contributing and protective factors.

Authors

Gala True, Department of Veterans Affairs, South Central Mental Illness Research Education and Clinical Center
Rosemary Frasso, Thomas Jefferson UniversityFollow
Sara W. Cullen, University of Pennsylvania
Richard C. Hermann, Tufts University
Steven C. Marcus, University of Pennsylvania

Document Type

Article

Publication Date

9-1-2017

Comments

This article is the authors' final version prior to publication in General Hospital Psychiatry, Volume 48, September 2017, Pages 65-71.

The published version is available at https://doi.org/10.1016/j.genhosppsych.2017.07.001. Copyright © True et al.

Abstract

OBJECTIVES: This study sought to identify risk factors and protective factors in hospital-based mental health settings in the Veterans Health Administration (VHA), with the goal of informing interventions to improve care of persons with serious mental illness.

METHODS: Twenty key informants from a stratified sample of 7 VHA inpatient psychiatric units were interviewed to gain their insights on causes of patient safety events and the factors that constrain or facilitate patient safety efforts.

RESULTS: Respondents identified threats to patient safety at the system-, provider-, and patient-levels. Protective factors that, when in place, made patient safety events less likely to occur included: promoting a culture of safety; advocating for patient-centeredness; and engaging administrators and organizational leadership to champion these changes.

CONCLUSIONS: Findings highlight the impact of systems-level policies and procedures on safety in inpatient mental health care. Engaging all stakeholders, including patients, in patient safety efforts and establishing a culture of safety will help improve the quality of inpatient psychiatric care. Successful implementation of changes require the knowledge of local experts most closely involved in patient care, as well as support and buy-in from organizational leadership.

Recommended Citation

True, Gala; Frasso, Rosemary; Cullen, Sara W.; Hermann, Richard C.; and Marcus, Steven C., "Adverse events in veterans affairs inpatient psychiatric units: Staff perspectives on contributing and protective factors." (2017). College of Population Health Faculty Papers. Paper 96.
https://jdc.jefferson.edu/healthpolicyfaculty/96

Creative Commons License

This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Language

English