Patient Safety Topics
Behavioral Health

​​​​​​​Events reported to the Pennsylvania Patient Safety Authority indicate that behavioral health patients continue to experience harm. Although no environment of care can be totally safe and free of risk, facilities can reduce the risk factors that have the potential to cause patient harm.

Key Data and Statistics

A variety of publications and initiatives from the Authority have addressed behavioral health issues reported by Pennsylvania healthcare facilities. Key data and statistics include the following:

Identifying suicidal intent in patients is difficult; in behavioral health, valid and reliable objective measurements and physiologic testing in the diagnostic process are lacking. The Authority reviewed events reported through PA-PSRS as "Suicide Attempt – Injury" that resulted in an unanticipated injury requiring additional healthcare services or events reported as "Suicide – Death" from May 1, 2015, through April 30, 2018. Of the 70 events identified, 81.4% (n = 57) were reported as "Suicide Attempt – Injury" and 18.6% (n = 13) were reported as "Suicide – Death". In 18.6% (n = 13 of 70) of event report narratives, it was mentioned that the patient either denied suicidal ideation or had been assessed as being of low risk for suicidal behaviors prior to the event. Of method of injury among event report narratives that indicated a low-risk assessment, 38.5% (n = 5 of 13) involved self-mutilation (e.g., cutting), 15.4% (n = 2) involved a jump from height, and one each involved hanging, gunshot, intentional overdose, car traffic, and train tracks. One narrative did not mention the method of injury.

Excerpted from: Mamrol C. Failures in the diagnostic process when assessing suicidal intent. Pa Patient Saf Advis 2018 Oct 31 [cited 2018 Nov 5].

Circumstances in the inpatient setting can result in psychiatric patients responding in an aggressive manner. Inpatient patient-to-patient aggression (47.2%, n = 538 of 1,139) was the behavioral health aggression–related event most frequently reported through PA-PSRS between January 1, 2012, and August 31, 2013.

Figure. Aggression Events Reported to the Pennsylvania Patient Safety Authority from January 1, 2012, through August 31, 2013, by Age Group (N = 1,139)

Note: Events reported for each aggression type are not mutually exclusive; therefore, the sum of the percentages for each cohort may exceed 100. There were 487 pediatric events, 588 adult events, and 64 geriatric events reported.

Excerpted from: Gardner LA, Magee MC. Patient-to-patient aggression in the inpatient behavioral health setting. Pa Patient Saf Advis 2014 Sep [cited 2018 Nov 5].

At the time of a September 2007 Advisory, the Authority had received through PA-PSRS more than 1,900 reports related to behavioral health issues, including suicide, self harm, violent behavior, and possession of items not permitted in the behavioral health environment that may contribute to harm. There were five reported suicides, although others may have been submitted only to the Pennsylvania Department of Health as Infrastructure Failures.

Examples of suicides reported through PA-PSRS include the following:

Patient was not in his bed for 7:30 a.m. bed check. Staff attempted to get in bathroom door but couldn't open the door. Staff immediately called security, who pushed open the door. Staff and security witnessed the patient falling behind the door as the belt he used to hang himself was released from the top of the closed door. Patient had no pulse or respirations. Paramedics were called, and patient was deceased.

  Patient was admitted with paranoia, anxiety, and agitation. When interviewed by the psychiatrist, he denied suicidal ideation. He was observed in the day hall watching TV with other patients in the evening. Later, a housekeeper entered his room and found him hanging by his shirt on the bathroom door. Staff called a code and began cardiopulmonary resuscitation (CPR) immediately. Resuscitation efforts were unsuccessful, and he was pronounced dead. 

Patient found on floor in bathroom with no respirations and faint pulse. His pants were around his neck as if he tried to strangle himself. Mouth-to-mouth resuscitation was given, and oxygen administration was initiated. 911 was called. The paramedics arrived and initiated CPR. The patient was transferred to the emergency room (ER) and pronounced dead. 

Excerpted from: Diligence and design in behavioral health impact patient safety. PA PSRS Patient Saf Advis 2007 Sep [cited 2018 Nov 5].
Educational Tools

Risky Rooms
These room diagrams identify potential ligature risks in various inpatient care settings and may be used for training staff or conducting an educational exercise. Both blank and labeled copies are available for each care setting.

How is it Possible to Keep Behavioral Health Patients Safe in the Acute Care Setting?
Safety Tips for Patients