Preventing Serious Reportable and Sentinel Events Within Psychiatric Inpatient Settings-A Scoping Review

Area of Science:

• Psychiatry
• Patient Safety
• Healthcare Quality

Background:

• Serious reportable events (SREs) and sentinel events pose significant risks in psychiatric settings, including suicide, assaults, and unexpected deaths.
• These preventable events necessitate a thorough understanding of their contributing factors and effective prevention strategies.

Purpose of the Study:

• To conduct a scoping review examining the risk factors and preventive strategies for serious reportable or sentinel events in psychiatric inpatient settings.
• To identify commonalities and differences in contributing factors and preventive measures across various types of SREs.

Main Methods:

• A systematic scoping review guided by PRISMA and Arksey and O'Malley frameworks.
• Comprehensive literature search across six major databases (CINAHL, Embase, PsycINFO, PubMed, ScienceDirect, Scopus).
• Inclusion of 29 articles focusing on inpatient suicide, general adverse events, assaults, abscondment, and sexual incidents.

Main Results:

• Inpatient suicide was the most frequently explored event (62.07%), followed by general adverse events (17.24%).
• Specific preventive strategies identified include means restriction for suicide, routine medical review for unexpected deaths, and gender segregation for sexual incidents.
• Consistent preventive strategies across all events involve robust guidelines, adequate staffing and training, secure ward environments, rigorous observation, and individualized risk assessments.

Conclusions:

• Patient and ward profiles, management, staffing, training, observation, risk assessments, and treatment are key factors associated with SREs.
• Strengthening these factors can significantly enhance patient safety and the quality of care in psychiatric inpatient facilities.
• A multi-faceted approach addressing systemic and individual factors is crucial for preventing serious adverse events in psychiatric care.