Patient and Staff Safety on Inpatient Psychiatric Units

Recently we’ve been working with medical center Behavioral Health inpatient units that have increasing patient and staff safety incidents. Most of these involve patient self-harm and/or staff injury. Here are some operational approaches to reducing psychiatric patient self harm and staff injuries.

CMS and Joint Commission physical plant ligature risk and suicide prevention reduction regulations are often in place. Program mitigations are also commonly used. In spite of these efforts, we often work with psychiatric service lines following serious incidents. Below are a few summarized observations about patient and staff safety from recent work with inpatient psychiatric units and Emergency Departments caring for behavioral health patients.

Acuity is higher. Hospital inpatient psychiatric units report frequent co-occurring mental health, substance use, and physical medical disorders among all age groups. 

Often there are not enough psychiatric nurses. Finding and keeping qualified psychiatric nurses and nurse leaders is difficult. In one BSN class of 40, only 3 graduates tried psychiatry but all three left within weeks. Often we find psychiatric nurses under recognized by hospital leadership.

Inpatient unit staff can become de-sensitized to risks. Contributing factors seem to be a constantly elevated census, high and complex acuity, insufficient qualified psychiatric nurse and licensed therapists, infrequent safety rounds. Staff tell us they are finding it hard to fully meet close observation, like one-to-ones, and other special precautions.

A common challenge for all staff working on inpatient psychiatric units and in Emergency Departments is becoming de-sensitized to the risks of patient self or other harm.  Unlike most medical patients, individuals in these settings often are so despondent and hopeless that they do not believe they “can get better” and in fact want to kill/harm themselves or may be so mentally compromised that they physically fight the staff trying to help them.

Some organizations have found procedures to help keep staff sensitized to potential patient suicide/self-harm and aggression. A few include:

  1. Using written Environment of Care Safety checklists (contact us for a sample form) for safety rounding on each shift for every patient room, bathrooms, corridors, and all common areas; some organizations require staff to sign the completed checklist forms each shift
  2. Providing structured, active clinical treatment activities (e.g. 6 or more structured therapy groups a day and into the early evening) adapted and modified to fit the needs of the patient population and acuity
  3. Conducting at least monthly unannounced senior Behavioral Health leadership safety rounding/tracers and ad hoc staff queries for each shift on patient safety, observation levels, patient management procedures and, importantly, solicit staff input; should include BH Senior VP, BH Quality Director, BH Nursing Director, BH Educator
  4. Starting daily reports with a “Safety Story” – what and how a staff person found and mitigated a risk
  5. Tracking and sharing safety trend reports from the above with all staff
  6. Establishing a front line quality team that reviews and provides staff input on relevant policies can help keep everyone’s attention, e.g. Behavioral Health Safety Observation Levels, Alerts and codes, Psychiatric Sitter, Restraint and Seclusion, Management of Behavioral Patient in the ED

About Steve Schafer

Founder and Senior Partner, Schafer Consulting, a national behavioral health consultant and management firm serving hospitals and health systems since 1993.

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