ArticlePsychiatric services (Washington, D.C.)2018
Safety of Psychiatric Inpatients at the Veterans Health Administration.
Article in Psychiatric services (Washington, D.C.), 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 19 papers, 2 of them syntheses that pooled it.
What it found
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
19 citing papers in PubMed, 2 syntheses or guidelines pooled it, 34 citations in OpenAlex.
- Patient safety incidents in the psychiatric inpatient setting: determinants, consequences, and strategies. A systematic review.Frontiers in psychiatry · 2025Pooled it
- Prevalence and solving strategies of drug-related problems in adult psychiatric inpatients - a systematic review.Frontiers in psychiatry · 2024Pooled it
- Mitigating risk in psychiatric hospital care for older adults by identifying adverse events with Global Trigger Tool for psychiatric patients.The International journal of risk & safety in medicine · 2026Article
- Institutional Betrayal in Inpatient Psychiatry: Effects on Trust and Engagement With Care.Psychiatric services (Washington, D.C.) · 2025Article
- Case Identification of Depression in Inpatient Electronic Medical Records: Scoping Review.JMIR medical informatics · 2024Article
- Machine Learning Classification of Psychiatric Data Associated with Compensation Claims for Patient Injuries.Methods of information in medicine · 2023Article
- Characteristics of Patients Who Complete Suicide and Suicide Attempts While Undergoing Treatment in Norway: Findings from Compensation Claims Records.International journal of environmental research and public health · 2023Article
- Patients Who Die by Suicide: A Study of Treatment Patterns and Patient Safety Incidents in Norway.International journal of environmental research and public health · 2022Article
- Prevalence, characteristics, and impact of Adverse Events in 34 Madrid hospitals. The ESHMAD study.European journal of clinical investigation · 2022Article
- Patient Safety and Mental Health-A Growing Quality Gap in Canada.Canadian journal of psychiatry. Revue canadienne de psychiatrie · 2022Article
- Psychometric analysis of Persian version of patient safety competency self-evaluation in psychiatric wards.Journal of education and health promotion · 2022Article
- Defining Patient Safety Events in Inpatient Psychiatry.Journal of patient safety · 2021Article
- Article
- The Effect of Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting Program on the Use of Restraint and Seclusion.Medical care · 2020Article
- Patient safety in marginalised groups: a narrative scoping review.International journal for equity in health · 2020Article
- Adverse events in psychiatry: a national cohort study in Sweden with a unique psychiatric trigger tool.BMC psychiatry · 2020Article
- Speaking up about patient safety in psychiatric hospitals - a cross-sectional survey study among healthcare staff.International journal of mental health nursing · 2019Article
- Comparing Rates of Adverse Events and Medical Errors on Inpatient Psychiatric Units at Veterans Health Administration and Community-based General Hospitals.Medical care · 2019Article
- Predictors of Adverse Events and Medical Errors Among Adult Inpatients of Psychiatric Units of Acute Care General Hospitals.Psychiatric services (Washington, D.C.) · 2018Article
Corrections and comments
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Authors and funding
4 authors.
Funding
Abstract
objectiveAlthough reducing adverse events and medical errors has become a central focus of the U.S. health care system over the past two decades both within and outside the Veterans Health Administration (VHA) hospital systems, patients treated in psychiatric units of acute care general hospitals have been excluded from major research in this field.
methodsThe study included a random sample of 40 psychiatric units from medical centers in the national VHA system. Standardized abstraction tools were used to assess the electronic health records from 8,005 hospitalizations. Medical record administrators screened the records for the presence of ten specific types of patient safety events, which, when present, were evaluated by physician reviewers to assess whether the event was the result of an error, whether it caused harm, and whether it was preventable.
resultsApproximately one in five patients experienced a patient safety event. The most frequently occurring events were medication errors (which include delayed and missed doses) (17.2%), followed by adverse drug events (4.1%), falls (2.8%), and assault (1.0%). Most patient safety events (94.9%) resulted in little harm or no harm, and more than half (56.6%) of the events were deemed preventable.
conclusionsAlthough patient safety events in VHA psychiatric inpatient units were relatively common, a great majority of these events resulted in little or no patient harm. Nevertheless, many were preventable, and the study provides data with which to target future initiatives that may improve the safety of this vulnerable patient population.
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