Question

Case 1:
A 45-year-old man with a history of depression presented to the ED with the complaint of feeling suicidal. The patient had cut himself after an argument with his wife. His family called 911; the police and EMS responded and transported him to the ED. The initial suicide screening revealed that the patient did not want to live and intended to kill himself. Because of this initial screening, the ED nurse initiated “high risk behavioral health precautions.” The physician ordered labs, suicide precautions with one-on-one observation, and evaluation by the on-call mental health counselor. Everyone agreed that the patient was at high risk of suicide and would require inpatient psychiatric admission.

The medical record showed that the patient was “placed in a gown and a safe ED room” and that suicide precautions were initiated. The ED nurse charting — performed at 15-minute intervals — indicated that security was at the patient’s bedside. While awaiting psychiatric admission and after several hours of observation, security briefly left the patient’s room; they returned to find the patient unresponsive, cyanotic, and hanging from the cardiac monitor with the monitor wires wrapped around his neck. The patient did not survive despite a code blue resuscitation.

Question 1. What went wrong?

Question 2: What should have happened?

Case 2:
Before a thorough evaluation could take place, a suicidal patient in the ED started screaming at the nurses that she wanted to leave. The patient was restrained supine by all four limbs. The 2 beds in the ED designated for behavioral health patients were full, so they put the patient in a procedure room, away from the nurse’s station. Since the patient was screaming and yelling, the ED staff was happy to isolate the patient in a room. The staff allowed her to keep her clothes on so as not to agitate her any further. They did not find weapons on her, but they also did not perform a diligent search for other objects that could be used to inflict harm.

Question 3. What went wrong?
Question 4: Review TJC National Patient Safety Goal
A.   Identify the specific goals that addresses suicide
B.   Research and review the elements of performance for the standard

Answer 1

Case 1:

1) The security personnel left the patient alone and the patient took this opportunity to kill himself by wrapping monitor wires around his neck .

2) The security personnel must have put some other healthcare personal on observation of the patient as the patient had high tendency for suicide to prevent this circumstance.

Case 2 :

3) What went wrong?

The nurse committed negligence by not checking her clothes thoroughly for any thing /object that can be used as a weapon .And also the patient was not put on one on one observation .

4) TJC National Patient Safety Goal :-

1. Improve the accuracy of patient identification

2. Improve the effectiveness of communication among caregivers.

3. Improve the safety of using medications.

4. Reduce the harm associated with clinical alarm systems.

5. Reduce the risk of healthcare-associated infections.

6. The hospital identifies safety risks inherent in its patient population