Reducing the risk of patient suicide in Tuscany

Abstract

Patient suicide is one of the most frequent incidents in healthcare facilities to be reported to the National Observatory of Sentinel Events in Italy. Despite national initiatives, in Tuscany potentially preventable patient suicides still occur in both acute and community care settings. We describe here an aggregated qualitative analysis of 14 patient suicides that took place in public health services between 2017 and 2018. We outline the methodology and results of an improvement action we enacted in the healthcare system that involved reviewing and reinforcing relevant managerial strategies and clinical activities, with the aim of reducing potentially preventable patient suicides.

The problem of patient suicide in Italy and in Tuscany

The Ministry of Health in Italy considers risk management to be a specific objective to be developed by national policies. The National Health Plan states that there is a need to guarantee and monitor the safety of healthcare and biomedical technology. To facilitate delivery of this objective a standardised computerised method has been introduced, which collects and analyses data on adverse events. Specific actions have been instituted to provide education and training for all stakeholders. This is conducted throughout the healthcare system, including governance, at national, regional and local levels. According to data from the National Observatory on Sentinel Events, patient suicide is the second most frequent type of event to be reported under the terms of the Plan, accounting for 15.4% of incidents over the period 2005 to 2012.¹ Incidents reported include suicides and suicide attempts that occurred during the delivery of healthcare services in hospitals or out-patient facilities. In 2008 the Ministry of Health published a recommendation for the prevention of in-patient suicide, asking healthcare organisations and professionals to improve preventive actions. The recommendation provided for the training of healthcare workers, the organisation of services and improvements to the work environment. Also in the audits conducted by The Joint Commission, the physical environment of the in-patient unit in which the suicide occurred was the most important contributory factor in 84% of reported incidents.² Despite the complexity of factors leading to patient suicide, the Ministry recognised that, when the event occurs during delivery of healthcare services, there would have been opportunities for prevention. Accordingly, recommendations were made for preventive measures to be taken, on the basis of evidence from research and professional consensus.³

Within this framework sits the Centre for Clinical Risk Management and Patient Safety of the Tuscany Region (Centre GRC), which is tasked to implement safety solutions and prevent suicides within healthcare facilities. The Centre GRC is a World Health Organization Collaborating Centre with a remit to improve the safety and quality of care. It provides a regional clinical governance structure that promotes safety culture through a ‘human factors and ergonomics’ approach to managing complex systems. The Centre GRC operates on a shared vision of safety. The emphasis is on sharing experiences and includes field practices for safety that accord with operational reality; it aims to highlight effective and critical interventions.

The systemic approach of the Centre to improving patient safety is strengthened by incorporating multidisciplinary expertise that includes expertise in public health, safety and quality, industrial design, human factors, sociology, communication science and law. The Centre acts as regional hub for the coordination of all the activities related to safety and quality of care within a broader network of structures and professional risk managers at the level of individual facilities. The Centre has, by means of facilitating collaboration, been able to build an implementation-research project with the cooperation of front-line staff.

The Centre GRC collects the data on patient safety incidents by using an advanced reporting and learning web-based platform. The system is called ‘SiGRC’ and has been developed with the intention of collecting reports about adverse events submitted on a voluntary basis, directly from front-line health workers. These reports are analysed on the basis of a narrative of the adverse events, to discover latent themes and thereby provide a learning opportunity.⁴

In the SiGRC, adverse events are categorised according to the International Classification for Patient Safety,⁵ and contributing factors are categorised according to an adapted classification of the London Protocol:⁶ (a) patient factors; (b) task and technology factors; (c) individual (staff) factors; (d) team factors; (e) work environment factors; (f) organisational and management factors; (g) institutional context factors.

Between 2007 and 2018, hospitals reported 48 suicides and 32 attempted suicides to the SiGRC and these events were analysed according to the specified criteria. The greatest proportion of suicides occurred in internal medicine units, where there were 14 incidents; psychiatric services reported 7 incidents and surgical services reported 6. The highest number of suicide attempts was registered among patients in penitentiary institutions (10 incidents), including 7 in mental health units and 3 in neurological units.

The national recommendation for prevention of risk has been part of the regional accreditation requirements since 2011. Despite this theoretical implementation of government policy, the incidence of similar suicides remained unchanged during the period of reporting (2007–2018). We therefore decided to perform an aggregated analysis of the sentinel events. Applying the methodology of systemic analysis and a human factors approach, we conducted a thematic analysis on data from six cases of completed suicide and eight cases of attempted suicide that occurred among in-patients at eight hospitals belonging to five public trusts between 2017 and 2018.

The analysis was conducted by a multidisciplinary team comprising experts in human factors, patient safety personnel from the regional centre, members of the clinical teams with responsibility for patient care, as well as risk managers from the participating trusts. We collected the available reports on SiGRC and prepared a summary of the aggregated analysis, with a short timeline for each case and descriptive statistics as shown in Table 1. We compared our data with those recently published by the USA's Joint Commission for the Accreditation of Health Organizations, which has a similar reporting structure for patient suicides⁷ and with a narrative review from the Mayo Clinic.⁸

Table 1 Structured data about the patients’ suicides (n = 6) and attempted suicides (n = 8) reported to SiGRC in 2017–2018

a Psychiatry refers to a hospital service where voluntary and compulsory psychiatric treatments are carried out during hospitalisation. It also carries out consultancy activities for other hospital services. It is located inside the hospital facilities.

b Mental health refers to the first reference center for citizens with mental illness. It coordinates all interventions for the prevention, treatment and rehabilitation of citizens with psychiatric pathologies within the territory.

Once the analysis that had been conducted at a local level had been confirmed, the team reviewed and integrated improvement actions that were not only specific for each event, but were scalable and potentially transferable to other settings. The main recommendations that emerged from the analysis of the narrative are summarised in Box 1.

Box 1 Recommendations to reduce risk of patient suicide in healthcare facilities

• • The introduction of an objective checklist to identify, at the point of admission, patients at risk of suicide would be valuable, because it would help to avoid the underestimation of risk factors.

• • There should be constant observation of patients who have been admitted after a suicide attempt, whether or not they have a history of mental health problems, until they have been seen by a psychiatrist.

• • There should be specific training for clinical staff who are potentially going to be in charge of patients at risk of suicide.

• • Sufficient time should be dedicated to the handover between staff who are responsible for patients at risk, both at the time of a shift change and at the time of transition between services.

• • Early identification of patients at risk and a better monitoring of behavioural signs and symptoms should be instituted throughout the continuum of care.

• • There should be improved continuity of communication of risks between professionals and services.

• • The design of in-patient units should permit clinical staff to maintain visual supervision of at-risk patients at all times, and physical hazards that might facilitate suicide should be removed or modified.

Discussion

Our narrative analysis revealed that most of the suicides and suicide attempts were unrelated to previously identified psychiatric disease. Several people who were admitted after suicide attempts described having suffered from social and economic marginalisation and deprivation. We recommend greater cooperation between social services and primary health services, including mental health services, to identify people who are experiencing adverse socioeconomic issues. They would be the first and more immediate point of contact for the population at large and are in a better position than hospital staff to detect those at socioeconomic risk.

To provide support for the professionals involved in the care of patients at risk of suicide, the regional Centre for Relational Issues is providing a long-term training programme on multiprofessional management of at-risk patients and prevention. This initiative had its origins in clinics serving penitentiaries and is due to be expanded to reach community mental health services. Individual health service trusts are expected regularly to update their policies and procedures for the prevention of patient suicide. Regional centres will monitor their implementation, and a ‘patient safety walkaround’ (PSW) agenda is to be enacted in 2020. The PSWs have proven to be an effective method of encouraging change. They reinforce the alliance between front-line staff and management and provide a safe and free-from-blame opportunity to discuss organisational successes and failures. So far, there have been two PSWs reviewing the penitentiary systems of the region. They assessed potential improvements to safety and the quality of care delivered to imprisoned people with mental disorders. These reviews have led to positive results in terms of improvement in the delivery of assistance to prisoners at risk of engaging in suicidal behaviours.