PATIENT SAFETY IN

PSYCHIATRIC WARD
PREPARED BY: AJISH THOMAS
MSC(N)II nd year
KEMPEGOWDA COLLEGE OF NURSING
 DEFINITION
• Definition: Patient safety was defined by the
IOM as “the prevention of harm to
patients.” Emphasis is placed on the system
of care delivery that (1) prevents errors; (2)
learns from the errors that do occur; and (3)
is built on a culture of safety that involves
health care professionals, organizations, and
patients.
 Patient safety incidents in mental
health
• patient safety issues that arise in the mental
health context are-
– Seclusion and restraint use,
– Self harming behavior,
– Suicide,
– Absconding and
– Reduced capacity for self advocacy.
 Suicide

• Definition:
– Suicide is the intentional act of killing oneself.
 FIVE LEVELS OF SUICIDAL THOUGHTS
• Suicidal ideation
• Suicidal threat
• Suicidal gestures
• Suicide attempt
• Completed suicide
 Risk factors for suicide
• Demographic factors
• Age: elderly, adolescent
• Gender: male
• Race white
• Psychiatric risk factors
• Major depression and bipolar disorder are
responsible for around 60% of completed
suicide, alcohol and drug abuse 25 %, psychosis
10% and personality disorder 5%.
Physical illness

• Medical factors: such as AIDS, Cancer, Head trauma,

Epilepsy, Cardiopulmonary disease etc
• Social risk factors: widowed, divorced, separated, solitary
living status, recent personal loss, unemployment,
financial difficulties.
• Familial factors such as family history of suicide, or
psychiatric illness, early parental separation or death
emotional or physical or sexual abuse.
• Past and present suicidality
• History of suicide attempts is one of the most powerful
risk factors for the completed and attempted suicide.
 Mood Disorders Suicide Attempts

15% of mood disorder 10% of attempts subsequently

subsequently suicide suicide within 10 years

Suicides
45-70% of suicides 19-24% of suicides have a
have mood disorder prior suicide attempt
Methods of suicide

• Most frequent method of in-patient suicide is

hanging
• Other methods include
– Jumping
– Injury by sharp
– Self poisoning
– Piercing of vital organs
 Assessment

• Assessment data must be gathered regarding any

psychiatric or physical condition for which the client is
being treated. Major depression and bipolar disorder are
the most common disorders that precede suicide.
• History of previous suicide attempt
• Family history of suicide.
• Every suicide ideation, gesture, impulse or attempt should
be taken seriously.
• Determine whether the individual has a plan and if so,
whether he or she as the means to carry out that plan.
• Presence of any precipitating stressors.
• Availability of interpersonal support system.
 Warnings signs of suicide
• Suicidal Talk
– “I Wish I Were Dead” “If ........Happens, I’ll Kill Myself” “No One Cares About
Me” “I Just Want All Of This To End”
• Most people with suicidal ideation send either direct or indirect signals to others
about their intent to harm themselves. Example: a client says, “You are the best
nurse I’ve ever met. I want you to remember me”. (indirect signal)
• Anti-depressant treatment can actually give clients with depression the energy to
act on suicidal ideation.
• Writing farewell letters.
• Giving away treasured articles.
• Making a will.
• Closing bank accounts
• Appearing peaceful and happy after a period of depression.
• Refusing to eat or drink.
• Less concern about personal hygiene.
 Interventions
• Ask client directly, Have you thought about
harming yourself in any way? If so what do you
plan to do? Do you have the means to carry out
the plan?
• Take all suicidal threats or attempts seriously and
notify a psychiatrist.
• Using an authoritative role: The nurse assumes
an authoritative role to help client to stay safe.
For example a client may want to be alone in her
room think privately. This is not allowed while she
is at an increased risk for suicide.
 If you’re at work, you’re on
watch….

Preventing suicide is the responsibility

of all staff 24/7

13
• Providing a safe environment: In-patient hospital
units have policies for general environmental
safety.
– Removing of sharp objects from the range of patient.
– One to one supervision by staff person is initiated.
Maintain close observation of client usually every 15
minutes checks.
– The clients are in direct sight of and no more than 2 to
3 feet away from staff members.
– Locking of doors.
• Initiating a no suicide contract: in such
contracts, clients agree to keep themselves
safe and to notify staff at the first impulse to
harm themselves.
• Make rounds at frequent, irregular intervals
• Spend time with client encourage client to
explore and verbalize feelings including anger.
Provide hostility release if needed.
• Encourage him to talk about his suicidal plans
or methods
• Provide expression of hope to clients by
unconditional positive regards.
• Enhance self esteem of the patient by
focusing on his strengths rather than
weaknesses.
• Creating a support system list
• Search for toxic agents such as drugs or alcohol.
• Do not leave the drug tray within the reach of the
patient, make sure the daily medication is swallowed.
• Remove sharp objects such as razor blades, knives,
glass bottles.
• Remove straps and clothing such as neck tie or belt.
• Do not allow the patient to bolt his door on the inside,
make sure that somebody accompanies him to the
bathroom.
• Patient should be kept in constant observation and
should never be left alone.
 Safety interventions for violent and
impulsive patient
• Psychological view of aggressive behavior
suggests the importance of predisposing
developmental or life experiences that limit
the person’s capacity to select non violent
coping mechanism.
 Factors limiting use of non violent
coping techniques
• Organic brain damage, mental retardation or learning disabilities.
• Severe emotional deprivation or over rejection in childhood.
• Victim of child abuse or as a observer of family violence
• Substance abuse.
• Psychiatric cause
– Command hallucination with violent content.
– Depression with psychotic feature may further increase the chances of
violence.
– Patient with bipolar depression and psychotic depression are at
greatest risk of suicide.
– Psychotic major depression patients were found to have greater
current depression severity, suicidal ideation and suicide attempt.
 Types of management
• Seclusion
• Restraint
• PRN medication
• De-escalation
• Alternative therapies
 Management of potentially violent
patient
• Environmental strategies
– Units that are overly stimulating, either visually or
aurally, may also increase aggressive behavior so the
level of sensory stimulation should be low to
moderate.
– TV, stereos, lighting, temperature, wall colors and air
quality should not be over stimulating.
– Inpatient unit that provide many productive activities
such as games, reading and group program reduce the
chance of inappropriate behavior.
 Behavioral strategies:

• Limit settings: limit setting is a non- punitive,

non manipulative act in which the patient is
told what behavior is acceptable, what is not
acceptable and the consequences of behaving
unacceptably. It is recognized that patient has
the right to choose a behavior and knows the
consequences of it. Limit should be clarified
before negative consequences are applied.
• Behavioral contract: if a patient uses violence
to gain control and make personal gains, the
nursing care must be planned to eliminate the
rewards the patient receives while allowing
the patient to assume as much control as
possible. Eg: head injured patients with low
impulse control can be told that staff will take
them for a walk if he can refrain from using
profanity for 4 hours.
• Time out: socially in appropriate behaviors
can be decreased by short term removal of
the patient from over stimulating and
sometimes reinforcing situations.
• Token economy: in this intervention identified
interpersonal skills and self care behaviors are
rewarded with tokens that can be used by the
patient to purchase specific items.
 Communication strategies:

• Talking down: say “John, you seem very angry.

Let’s go to your room and talk about.
• Speaking to a patient in a calm, low voice can
help to decrease a patient’s agitation. It is
important that nurses not respond by raising
their voice, since this will likely be perceived
as competition and will only further escalate
the volatile situation.
 Physical outlets
• : provides effective way for client to release
tension associated with high levels of anger.
Eg: “may be it would help if you punched your
pillow or the punching bag for a while.
• Medication: give injection haloperidol (5 mg
IM/IV) with or without lorazepam (2mg IV).
Repeat if necessary.
 Seclusion
• The rationale for the use of seclusion is typically based
on 3 principles.
– Containment: patient is restricted to a place where he is
safe from harming himself and the rest of the unit is also
safe.
– Isolation: some patients, particularly those with paranoia,
distort the meaning of the interactions around them. This
distortions create such psychic pain that seclusion may
provide feeling safe from their ‘persecutor’
– Decrease in sensory input: the quiet atmosphere and
monotony of seclusion room may provide some relief from
the sensory overload.
 Safety guidelines for managing
aggressive and impulsive patient
• Have sufficient staff to indicate show of strength may be
enough to de-escalate the situation.
• Have less furniture in the room and remove sharp objects,
ropes, glass items, ties, strings, match boxes etc from
patient vicinity.
• Keep environmental stimuli, such as lighting and noise level
to a minimum.
• Remove hazardous objects and substance.
• Stay with the patient as hyperactivity increases to reduce
anxiety level and foster a feeling of security.
• Redirect violent behavior with physical outlets.
• Encourage the patient to ‘talk out’ his aggressive feeling,
rather than acting them out.
• If the patient is not calmed down by talking down
and refuses medications restraints may become
necessary.
• If patient is having a weapon ask him to keep it
on a table or floor rather than fighting with him
to take it away.
• Give prescribed antipsychotic medication.
• Patient can be discharged when psychiatric
symptomatology has resolved and which is
unlikely to recur.
TECHNIQUE FOR MAKING RESTRAINT
SAFER
• Definition: A restraint is any manual method,
physical or mechanical device, material or
equipment that immobilizes or reduces the
ability of the patient to move his or her arms,
legs, body or head freely
 Indications of 4- point restraints

• When the patient is physically combative.

• When the patient is a clear and immediate
danger to self or others.
• When less restrictive alternatives have been
attempted without success.
• When it reasonably appears that delay in
restraint would subject the patient and others
to risk of serious harm.
 Complications
• Abrasion and bruises.
• Dislocation, numbness, tingling, fracture or muscle
strain.
• Positioning the patient prone increases the risk of
suffocation.
• Positioning the patient supine without elevating the
head of bed increases the risk of aspiration.
• If a patient is not chemically sedated while physically
restrained, prolonged struggling may lead to
hyperthermia, lactic acidosis and elevated creatinine
kinase level. Laboratory studies should be obtained if
suspected as the patient may need medical admission.
 Technique:

• Proper technique starts with having a sufficient member of

personnel. Ideally there should be a five member team,
with one leader and one member for each extremity.
• Clearly explain to the patient and patient’s family what you
are doing as the restraints are being applied and explain
why you are applying the restraints.
• Do not apply the restraints to the bed rails.
• Restraints may need to be applied one at a time while the
other extremities are held down.
• Offer the patient medication, but if necessary administer
medication or chemical restraints involuntarily.
• Observe the client in restraints every 15 minutes.
Ensure that circulation to extremities is not
compromised (check temperature, color, pulses).
• Assist client with needs related to nutrition,
hydration and elimination.
• Document all observation.
• Orders for behavioral restraints must be limited
to the following-
– 4 hours maximum for adults.
– 2 hours maximum for children and adolescence.
– 1 hour maximum for children younger than 9 years.
• It is the duty of the health care professional to
discontinue the use of four point restraint as soon
as possible once it is deemed safe to do so.
• If the decision is made to remove the restraints,
remove one at a time while carefully monitoring
the patient to ensure safety.
• Staff debriefing: Debriefing helps to diminish the
emotional impact of the intervention, mutual
feedback is shared and staff has an opportunity
to process and learn from the event.
 Bibliography
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http://www.nursing.health.wa.gov.au/docs/career/np/NMAHS/SCGH_Aggression.pdf
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[document on the internet]. British Columbia mental health and addiction services; 2009. Available
from:
http://cpsi.sharepoint.ms/English/research/commissionedResearch/mentalHealthAndPatientSafety
/Documents/Mental%20Health%20Paper.pdf
• www.hamiltonhealthsciences.ca