Most people working in healthcare are now familiar with the concept of patient safety – and its fundamental underlying principle that services can be considerably improved with better outcomes for patients simply by doing less harm. No-one goes to work intending to harm people but strong evidence suggests that avoidable adverse events and mistakes have a huge impact on patients. The acute programme in Scotland is nearing its goal of reducing mortality in acute hospital settings by doing this very thing ie avoiding harm where possible. Lives are being saved.
On the back of this patient safety programmes are now rolling out in mental health and primary care.
Is there anything unique to patient safety in mental health?
(These accounts are anonymised but based on real patient experiences)
John was first admitted to hospital when he was only 19 and had developed what sounded like a schizophrenic illness. He had become withdrawn and increasingly paranoid. He had been using drugs as is not uncommon and on admission to, in those days, the Crichton, he was very agitated, attempted to leave and so was ultimately transferred out of region to an intensive psychiatric care unit.
This was all part of a very terrifying experience – “I look back now and I remember feeling that everyone was against me and not really knowing what was going on. When I got to the IPCU I immediately felt that I was being locked up and punished for something that I didn’t think I had done. I got angrier and angrier and ended up fighting the nurses. After a while, with the medication on board I felt a bit calmer but became aware of the other patients and that some of them were even more frightening than the nurses. One of them suggested to me that the pills I was taking were doing more harm than good and I would be better taking some “blow” (cannabis). I really didn’t want to do this because I was starting to realise that maybe I had been ill and maybe that things I believed had happened and the voices were all in my head. I would have loved to have had the chance to speak to one of the nurses but I really didn’t trust them. I remember going to the office where they all sat inside while we were wandering about – I knocked on the door and was told “2 minutes” – I went off and got the cannabis.”
Clearly John’s account is coloured by the fact that he was suffering a paranoid illness at the time but he gives a very striking description of being afraid, not knowing who to speak to, and his attempts to be heard falling on deaf ears – “2 minutes”. Does the way he was managed constitute less than ideal care? Probably. Does it constitute unsafe care? The idea of sending him to the IPCU was to make him safer to protect himself from his behaviour and to protect others – but the way, in which it was done, the level of involvement that he had in the process may have left him feeling less and less safe.
ALAN & JEAN’S STORY
Alan is an accountant whose wife Jean developed a puerperal psychosis a number of years ago, again necessitating care in a psychiatric inpatient unit.
Alan recollected “I remember going to the ward when Jean had been admitted. Our baby son was too small to go into the hospital with her they told me and I looked after him with a bit of help from relatives. He did eventually get to go to hospital and stay with his mum but only after a few weeks. Those first few weeks were hellish – she was really quite disturbed, kept gathering things together, talking about daft stuff which was described as a manic state. She certainly talked a lot, I remember visiting her and she was looking in a hell of a state which was unlike her, she was normally very well presented (she is a professional person herself) and there she was in a baggy dressing gown which was gaping open revealing huge damp patches on her nightie where she was leaking breast milk.
What really bothered me was that she had struck up a friendship with one of the blokes on the ward and I am quite certain that he thought he had a chance of becoming her “boyfriend” giving the disinhibited way she was acting. I remember speaking to the nurses who said that they were aware of this and they would keep an eye on it. I didn’t think she was safe.”
PATIENT SAFETY IN MENTAL HEALTH SETTINGS
The two patient stories above illustrate different aspects of possible harm and the Scottish Patient Safety Programme in Mental Health (SPSP-MH) is set up to try and address these and the other forms of harm which perhaps people more immediately think of. As with adverse events in general for acute hospital settings, medication error and falls account for the bulk of all adverse events. However failing to protect vulnerable patients, either from their own actions (self harm, disinhibited behaviour etc) or from the exploitation of others are also adverse events and causes of harm which the programme tries to address, as is the risk of violence to others.
THE SCOTTISH PATIENT SAFETY PROGRAMME
The SPSP-MH is a four year programme and by the end of the 4 years it is hoped that harm in mental health settings will be significantly reduced. The baseline measurement of where harm occurs is being carried out at the moment and an overall target will be developed as the programme further develops.
There are a number of work-streams including work around risk management, communication at transition points, seclusion and restraint, and medicines management. There is also an overarching area of work looking at culture and leadership, with a genuine emphasis on service user involvement running through the programme.
A very important aspect of measuring the success of a programme to make mental health services safer, has been around the development of a patient safety climate tool for service users. The local team in Dumfries, based in Balcary ward, have been heavily involved in helping develop this which was initially created by service users themselves linked to the organisation VOX (voices of experience). Even during the pilot phase of developing this tool- useful insights into what makes patients feel safe or unsafe have been highlighted.
WHY IT’S IMPORTANT TO LISTEN TO PATIENTS
The description of the early experience of using the patient safety climate tool for service users takes us back to why it’s important to hear stories such as John and Alan & Jean’s. Ultimately the patient safety programme in mental health will measure its success by a reduction in adverse events and by mapping changes in the ‘basket of measures’ which has been developed. However, if wards or services exist where patients, or staff, describe feeling unsafe and insecure then the programme will have failed, in my opinion. I would also suggest that patients in general hospitals may not always feel safe or that they know who to speak to or that they are being heard. The phrase “2 minutes” might sometimes be used by staff to patients in general hospital wards? It may be that the Patient Safety Climate Tool for patients is something which could be applied across all health facilities?
I will give the last word to John. “I have now been in and out of hospital for the last 7 or 8 years but I have to say that in the last year I actually asked to go in a couple of times because I knew I was struggling. It’s a nice new ward but the thing that I noticed most was that the staff really seem to have a bit more time to listen to you and I felt that I could go and ask them for help when I needed it. There were some folk who I was still a bit wary of, but I also found space and time for myself so I didn’t feel intimidated and I felt a lot happier hence asked to go in. I think you can just sense sometimes when a place is going to help you rather than make you feel worse.”
Dr David Hall is a Consultant Psychiatrist, Clinical Director Mental Health NHS D&G and National Clinical Lead SPSP-MH
Next weeks blog will be by Murray Glaister from the IT Dept
If you are enjoying reading the blog you may wish to take a look at this blog from Building Healthy Communities in the Machars , www.bhcmachars.blogspot.co.uk