Franklin James Cook

Psychiatrists’ Book on Patient Safety Says Communication Is Key

In Intervention, Postvention, Prevention on January 18, 2009 at 10:49 am

apa-patientsafety-suicidecover1ORIGINAL REPORTPsychiatric News announces the American Psychiatric Association’s publication of “a 33-page handbook that addresses ways to develop and integrate systems to reduce or prevent six critical events: suicide, aggression, falls, elopement, medical comorbidities, and drug or medication errors” [emphasis added].

Like the rest of the patient-safety movement, [“SAFE MD: Practical Applications and Approaches to Safe Psychiatric Practice”] emphasizes a shift away from blaming medical professionals for mistakes and toward creating systems that produce safe practices, wrote the editors. “The likelihood that an individual will commit an error is far greater in systems that are poorly organized and that have weak procedures and regulations,” they said. “A good staff member cannot combat a bad system.”

This systemic approach to safety garnered attention following a 1999 report by the Institute of Medicine, To Err Is Human, that concluded

“The majority of medical … errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them … Thus, mistakes can best be prevented by designing the health system at all levels to make it safer–to make it harder for people to do something wrong and easier for them to do it right.”

In the Psychiatric News report, Dr. Lucian Leape of the Harvard School of Public Health says that

the systemic approach has produced progress since the IOM report came out. “There’s been a tremendous increase in activity, concern, and action and a real improvement in safety. The most important new development is the movement away from procedural guidance to teamwork and relationships.”

Dr. Alfred Herzog, one of the handbook’s editors, says that in psychiatry “‘the human interaction is critical'” because safety protocols for medical practices, such as surgery, that are centered around procedures differ from safety practices for psychiatry, which is centered around what he describes as “‘a cognitive-awareness process.'”

“The psychiatrist must ask, ‘What information do I need, and what steps do I take to assure safety with this patient?'”

If one thread runs through the [handbook], it is communication. Psychiatrists need to communicate closely and continuously with other members of the treating team, as well as with patients and their families.

[Editor’s note: SPNAC readers may download an excerpt from the new handbook, containing only the chapter on suicide. Any caregiver who is a psychiatrist or who desires to work collaboratively with psychiatrists should  also see the APA Practice Guideline “Assessment and Treatment of Patients With Suicidal Behaviors.”]

[The abridged URL for this post is .]

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