Critical Analysis of a Patient Safety Incident Case Study Answer

Introduction

A patient safety incident is any unexpected or unforeseen event or scenario that could have or did result in harm to a patient. This includes harm caused by an illness or treatment outcome that did not fulfill the patient's or clinician's expectations for progress or cure. The case of a 38-year-old White British man, Gary has been selected for analyzing patient safety incident whose terrible outcome raises serious issues regarding patient safety. This introduction section includes incorporating discussions on risk assessment, human factors, as well as change theory within the broader context of the ensuing study.

As per the author Kaya, (2018), risk assessment is considered to be critical as it helps to detect, monitor, analyze, reduce, as well as prevent hazards within the healthcare environment. The 'INSIGHT' section of the main body of this study will meticulously examine these risks, drawing upon established literature regarding risk assessment frameworks in mental health settings (Pascarella et al., 2021). In context to Gary’s incident, it can be said that the inadequacies in risk assessment protocol might have contributed significantly to causing subsequent tragedy.

In addition, this study also discusses about the human factors which basically involve all of the possible factors that can impact the behaviour as well as performance of human beings in a system (Vaismoradi et al., 2020). As per the views of O'Connor et al., (2021), these factors are said to be critical in comprehending the patient safety incidents as they influence the patient safety cases. In the context of this case study of Gary, the human factors will be examined in detail in the 'INVOLVEMENT' section. This will analyze about the communication failures, knowledge gaps, and a lack of collaboration between mental health professionals contributing to the tragic outcome (O'Connor et al., 2021). Moreover, it can be said that the human factors determine how the healthcare professionals interact, communicate, as well as make decisions within their work environment (HEE, 2019). This analysis will be rooted in pertinent literature on human factors within healthcare, highlighting the pivotal role of effective communication and interdisciplinary collaboration in ensuring patient well-being (O'Connor et al., 2021).

In accordance to the works of Harrison et al., (2021), change theory encompasses organized frameworks and models that help the healthcare workers navigate intricate systems to bring about constructive and long-lasting transformation. It forms the cornerstone for initiating, implementing, and sustaining transformations aimed at enhancing patient care, and safety. The change theory is linked to the ‘IMPROVEMENT’ section which becomes a critical element in crafting the recommendations. These suggestions will be in line with accepted norms and evidence-based practices, when placing new safety and care quality measures into effect (Nilsen et al., 2020).

The authors Vaismoradi et al., (2020) highlight the fact that positive change recommendations will be developed directly from the prior examination of the patient safety incident. Moreover, this change theory acknowledges the difficulties involved in implementing new procedures or modifying existing ones and offers an organized method for comprehending the change (Nilsen et al., 2020). It will not just propose changes but also consider implementation strategies and potential barriers, grounded in referenced literature supporting the suggestions.

INSIGHTS

Risk 1: Failure to collect appropriate data regarding patient:

The failure to collect proper patient history, particularly from Gary’s partner Darren stands as a significant risk factor as per this incident. The police and frontline clinicians failed to leverage Darren’s intimate knowledge of Gary’s baseline behaviors and mental health changes at multiple key junctions. However, despite knowing that Darren directly observed Gary suffering from hallucinated voices, the clinicians and officers never once interviewed him in depth or during Gary's arrest and hospitalization. His observations could have provided invaluable information for establishing a comprehensive understanding of Gary's mental health state. In the views of Fitzpatrick et al., (2020) feedback from close relatives sometimes offers context that helps ground personnel with self-reports, especially in situations when insufficient information may prevent oneself from consciously or unconsciously realizing functional changes.

It can be said that this critical risk directly violates best practice standards emphasizing the importance of third-party validation in mental health examinations. According to the works of Fitzpatrick et al., (2020), absence of such crucial insights resulted in delayed recognition of potential psychosis and self-harm indicators over several months. From the views of Lustgarten et al., (2020), it can be said that feedback from Darren might have provided a different perspective for clinicians to view Gary's behavior. In the case of Gary, chances to elucidate the clinical picture were lost because Darren's collateral history and long-term data of mood variability were not obtained. Looking more closely at Darren's story might have confirmed the emergence of psychosis far sooner, as opposed to merely attributing behaviors to cocaine intoxication.

Unfortunately, Gary's repeated exclusion of Darren throughout his decline signalled explicitly that his relevant information remained undervalued and undesirable (Johnson et al., 2020). Because of this systemic exclusion, Gary's self-report became the only source of information available to clinicians, which led to an unnoticed progression of his insanity until he committed suicide (Fitzpatrick et al., 2020). So, it can be said that intervention areas could have been identified much sooner if Darren had been invited, included, and respected for his participation.

Risk 2: Premature discharge without follow-up:

Another risk which is identified in the incident of Gary is premature discharge without establishing any follow-up appointments. Discharging Gary prematurely, after only two weeks of inpatient assessment, without setting follow-up appointments constituted a significant breach of continuity of care principles (Alper et al., 2017). His hearing hallucinations and suicidal thoughts were not well addressed by this premature discharge. This demonstrated a lack of consideration for the vulnerability of people recuperating from severe mental health emergencies (Moyo et al., 2020).

Particularly in the aftermath of major mental health crises, patients remain extremely susceptible, navigating cognitive limitations combined with profound despair, stressing their existing limited coping capacities (Alper et al., 2017). Gary's need for continuous intensive therapy and periodic examinations to stabilize his condition was obvious, yet he was discharged without this critical safety net in place. The authors Rustad et al., (2017) highlighted that the absence of a structured transition plan and follow-up care posed a considerable risk to Gary's well-being. It can be said that Gary's susceptibility to impulsive or irresponsible behaviors increased when clinical supervision was prematurely removed, potentially leading to negative outcomes. It can be said that this abrupt discontinuation of care may have led to Gary's rapid decline only five weeks after release.

Therefore, it can be said that Gary could have recovered more smoothly if his treatment had followed a more nuanced trajectory that included a continuum of care and frequently allowed transitions between outpatient services and inpatient respite. By the views of Rustad et al., (2017) it can be said that such approach would have enabled early interventions and continuous support to address concerning signs before they worsened. From the research works of Alper et al., (2017) it is acknowledged that skilled clinicians hold a duty to remain vigilant to signs pointing towards potential deterioration. The important signs that highlighted the vital need for ongoing, structured support and thorough care planning in mental health settings were disregarded in this case.

Risk 3: Suicidal Tendency :

In the case study Gary disclosed hearing two voices telling him to end his life. Suicidal ideation is a serious risk factor for individuals with mental illness. It indicates a heightened vulnerability and requires immediate attention from mental health professionals. Timely intervention, support, and appropriate treatment can significantly reduce the risk of self-harm or suicide.

Risk 4: Poor psychosocial support/engagement:

The mental health systems often encounter the challenging task of reconciling clinical concerns with personal aspects, particularly when dealing with patients like Gary, who face challenges like acute psychosis and distress of a recent breakup in a committed relationship. The care team failed to recognize the significant impact of Gary's sudden separation from Darren, even as they focused on treating Gary's schizophrenic symptoms and active suicide ideation with medication and therapy.

Additionally, the underestimation of providing psychosocial care customized to Gary's emotional needs following the relationship split represents a serious risk (Mukdarut et al., 2017). The primary focus of the treatment team on controlling clinical symptoms overshadowed the crucial task of attending to Gary's intense emotional pain following the separation (Mukdarut et al., 2017). Gary's drive to seek stability may have been undermined by the lack of assistance in addressing his complicated emotions around the breakup and its aftermath, as well as the therapeutic connection.

The trust of Gary in the care system was weakened by the disregard shown by the mental health care team for his emotional suffering caused by his grief burden (Dekel et al., 2022). By disregarding the significance of Gary's grief amidst his struggle with psychosis, the care providers inadvertently conveyed a message of minimal validation or acknowledgment of his emotional pain. A more compassionate approach that acknowledged and handled Gary's emotional distress could have encouraged trust and involvement with the care system (Dekel et al., 2022). By the views of (Mukdarut et al., 2017), it can be said that psychoeducation about experiences of grief, healthy coping mechanisms and acceptance strategies could have offered Gary a supportive lifeline amid feelings of abandonment

Risk 4: Risk of self harm:

Gary stated he constantly had thoughts to kill himself. Self-harm poses significant risks for individuals dealing with mental health challenges. Physically, it can lead to infections, scarring, and complications, while emotionally exacerbating feelings of guilt and shame. Additionally, self-harm may indicate underlying issues that require professional intervention. Seeking support from mental health professionals, friends, or family is crucial to address the root causes and develop healthier coping mechanisms.

Risk 6: Risk of overdose:

(Amitripytline anti-depressant). Side effects according to NICE guidelines can increase the risk of suicidal thoughts/behaviour; people who have started these anti-depressant therapy should be watched closely for signs of changes in behaviour or worsening depression.

Involvement

Human factor 1: Inadequate Involvement of Collateral Sources:

The inadequate involvement of collateral sources, specifically Gary's ex-partner Darren, impacted significantly the comprehensive assessment as well as subsequent care decisions in the mental health journey of Gary. Collateral sources, like family members or close acquaintances, frequently possess significant insights about a person's behavioural patterns, triggers, and early symptoms of mental health difficulties (Fitzpatrick et al., 2020). In context to Gary's case, Darren's observations regarding Gary's behavior and experiences were crucial in providing a more holistic understanding of his mental health state (Burgener, 2020). However, the failure to actively engage Darren during assessments led to a substantial information gap in understanding Gary's condition.

In accordance to a research author, Fitzpatrick et al., (2020) collateral sources play a vital role for accurate risk assessments and the development of specialized solutions in mental health assessments. When conducting clinical assessments, individuals may withhold information from their own sources, such as behavioral observations, historical context, and subtle details (Burgener, 2020). So, the failure to engage Darren represents a missed opportunity for the healthcare team to gather essential information that could have influenced care outcomes positively. Darren's observations might have shed light on triggers or warning signs that could have been addressed in initial times, potentially preventing adverse outcomes (Burgener, 2020).

Human Factor 2:Communication Breakdowns among Healthcare Providers:

One of the most important human factors influencing the patient safety incident concerning Gary was the breakdown in communication among healthcare staff. Based on the research works of Guttman et al., (2021), it is understood that effective communication is significantly necessary in providing high-quality healthcare. Moreover, the works of Burgener, (2020) suggest that communication helps in preventing medical errors, enhancing patient outcomes, and thereby ensuring coordinated care. Where we discussed near misses and critical incident, please can we also include a bit of professional governance: (Mental Health act (1983), Mental Capacity Act (2005), Deprivation of Liberty Safeguards and

Certainly, we can discuss the intersection of near misses, critical incidents, and professional governance, including relevant acts like the Mental Health Act (1983), Mental Capacity Act (2005), and Deprivation of Liberty Safeguards. How can I assist you further in understanding or exploring these topics?

On a general patient with suicidal tendencies

When dealing with a patient exhibiting suicidal tendencies, it's crucial to approach the situation with care and follow professional guidelines. The Mental Health Act (1983) in the UK, for instance, allows for the detention of individuals deemed at risk to themselves or others. The Mental Capacity Act (2005) emphasizes respecting a person's autonomy but permits intervention if someone lacks capacity and their safety is at risk.

Deprivation of Liberty Safeguards is relevant when considering restrictions on a person's freedom of movement in a care setting. In such cases, ethical and legal considerations must be carefully balanced to ensure the patient's safety while respecting their rights. If you have specific questions or concerns, feel free to ask for more targeted information. However, the fragmented communication observed in Gary's case resulted in significant gaps and limitations within his care trajectory.

The consequences of this communication breakdown showed out in a number of ways. Firstly, it prevented the interdisciplinary team caring for Gary from exchanging thorough information with one another (Burgener, 2020). The vital observations and insights from different healthcare professionals might not have been shared adequately, leading to an incomplete understanding of Gary's condition (Guttman et al., 2021). In addition, it can be said that this communication breakdown could have resulted in disconnected treatment delivery (Guttman et al., 2021).

Secondly, the absence of this human factor also has a profound impact on the decision-making processes and timely adjustments in Gary's care regimen. Delays in interventions and lost chances to identify warning indicators of Gary's deteriorating mental health are probably consequences of the broken communication (Guttman et al., 2021). The author Burgener, (2020) highlights the fact that when critical information fails to reach all relevant team members promptly, it impedes the healthcare team’s ability to make informed decisions regarding the patient’s health swiftly. As a result, crucial measures may have been postponed or delayed, allowing Gary's condition to worsen uncontrollably (Rodziewicz and Hipskind, 2020). Moreover, by the works of Guttman et al., (2021) it is also realized that inadequate communication might have resulted in a lack of timely adjustments in Gary's care regimen

Human factor 3: Knowledge gaps regarding cultural humility and suicide prevention:

This particular human factor of knowledge gaps regarding cultural humility and suicide prevention among clinicians significantly impacted Gary's care and therapeutic outcomes (How et al., 2020). The clinicians showed little understanding of the emotional and cultural subtleties that surrounded Gary's grief following his split from his partner, Darren. Cultural humility, a fundamental principle in healthcare, advocates for examining patients within the context of their broader sociocultural backgrounds (Hussen et al., 2020). In Gary's case, the clinicians' ignorance of these cultural nuances prevented them from acknowledging and managing the significant emotional impact of the relationship breakdown on his mental well-being (How et al., 2020). So, it can be said that by overlooking the cultural aspects contributing to Gary's distress, the clinicians failed to avail a crucial opportunity to provide holistic and culturally sensitive care.

Duty of candour in risk management for a patient with suicidal tendencies and self-harm involves a commitment to open communication. Healthcare professionals are obligated to be honest with the patient, discussing potential risks, preventive measures, and involving them in the decision-making process regarding their care. This transparency fosters trust and ensures that the patient is informed about their condition and the associated risks. It also helps in creating a collaborative approach to managing and mitigating the risk of self-harm or suicide.

During therapeutic encounters, Gary's intense personal loss, which consumed much of his emotional state, was disregarded or left unacknowledged. This failure to recognize his mental discomfort points to a serious weakness in the care that he was receiving (How et al., 2020). Instead, the focus of the healthcare team remained narrowly on symptom management, ignoring the culturally ingrained origins of Gary's unhappiness. As per the authors Hussen et al., (2020) it can be said that neglecting culturally significant issues can hinder therapeutic alliances and worsen patient outcomes. The consequence of this knowledge gap was evident in Gary's withdrawal and mistrust of the care system (Hussen et al., 2020). By ignoring the emotional consequences of the relationship split, therapists missed an important chance to engage Gary on a more individualized and compassionate level (How et al., 2020). Therefore, it can be said that customized therapy which addresses the patient’s nuanced feelings about the breakup of the relationship might have helped him stop withdrawing and increased his faith in the system of care.

IMPROVEMENT

Recommendation 1 : Establish Structured Follow-Up Care Plans:

In order to comply with the recommendations made by the NICE (2018), it is imperative that discharged patients, especially those who have recently gone through an acute mental health crisis have formal follow-up treatment plans. The development of standardized discharge protocols ensures that persons transferring from inpatient treatment to community settings receive continued assistance and monitoring (NICE, 2018).

Such structured post-discharge plans should encompass several key components. Firstly, regular follow-up appointments should be organized to monitor the patient's development, evaluate therapy efficacy, and address any emergent issues or needs as soon as possible (Kowalkowski et al., 2019). These appointments can serve as crucial touchpoints to assess the patient's response to interventions and adjust the care plan accordingly (Kowalkowski et al., 2019). In addition, personalized support strategies tailored to the individual's needs should also be incorporated into the care plan (NICE, 2018). This may involve providing access to community resources, therapeutic interventions, or social support networks designed to assist the patient in managing their mental health condition effectively (Kowalkowski et al., 2019).

Moreover, primary care providers must get an accurate and transparent transfer of responsibility. This ensures that the patient's ongoing mental health needs are effectively communicated and managed within the community setting (Kozlowska et al., 2018). It encourages collaboration between levels of care and reduces the possibility of gaps or disturbances in care continuity, thereby lowering the likelihood of relapses or crises (NICE, 2018). Therefore, it can be said that by implementing structured follow-up care plans, the healthcare providers can ensure a smoother transition for patients, mitigating the risk of adverse outcomes as well as supporting long-term mental health recovery.

Recommendation 2: Implement standardized collateral history protocols:

Establishing uniform collateral history processes within mental health examinations is essential for capturing comprehensive and accurate data required for reliable risk assessments (Chang et al., 2020). The protocol should require systematic questions and documentation of facts offered by families or caregivers regarding symptoms, behavioral changes, and the individual's risk history (UK Parliament, 2023). Currently, relying on self-reported information frequently leads to important oversights, particularly in complex cases such as Gary's, where critical information from secondary sources was overlooked (Chang et al., 2020). Such errors would be minimized and a more comprehensive evaluation would be guaranteed by implementing structured form templates created to request and record third-party viewpoints (UK Parliament, 2023).

The NHS might implement comparable guidelines to encourage caregiver participation and feedback by taking cues from global models such as Canada's interRAI suite, which places a strong emphasis on obtaining collateral information (NHS, 2015). Overcoming these obstacles might involve transparent communication, explicitly explaining how additional insights contribute to more individualized and effective care plans (NHS, 2015). Proactive measures. such as obtaining permission to transmit pertinent health information, could improve access to critical information (NHS, 2015).

Collateral evidence might not always be flawless or free of problems, but combining data from several sources improves the objectivity and precision of risk evaluations (Chang et al., 2020). Despite potential barriers, the ethical obligation to gather a comprehensive background remains pivotal in upholding patient safety and ensuring that care plans are tailored and effective (Chadwick and Gallagher, 2020). Establishing standardized collateral history protocols represents a fundamental step in enhancing the thoroughness and accuracy of mental health assessments.

Recommendation 3: Enhance Interdisciplinary Communication Frameworks:

In order to promote comprehensive and cooperative care, it is essential to strengthen the channels of communication between healthcare providers (Sheehan et al., 2022). It is imperative to establish established communication protocols, such as holding frequent multidisciplinary team (MDT) meetings or enabling interprofessional information sharing through the use of electronic health records (EHRs) (Janssen et al., 2018). These approaches align with the guidelines from the Royal College of Psychiatrists (RCPsych) advocating for enhanced communication strategies in mental healthcare (RCPSYCH, 2023).

Implementing robust communication technologies to promote seamless knowledge exchange across all health and social care providers involved in an individual's care is an essential priority based on Gary's trajectory (Kozlowska et al., 2018). Creating well-defined, uniform frameworks is in line with best practice guidelines that prioritize interdisciplinary coordination (Janssen et al., 2018). Some examples of this include integrated electronic health records that are accessible to the right providers, discharge protocols that are agreed upon by consensus and include role assignments, and multidisciplinary team meetings that are routinely recorded (Sheehan et al., 2022).

Unfreezing:

Recognize the need for change in mental health practices to enhance safety and quality.

Raise awareness about existing issues, such as outdated procedures or insufficient safety measures, to create a sense of urgency.

Changing:

Implement evidence-based practices and interventions to improve mental health care safety and quality.

Provide training for mental health professionals to adopt new and effective approaches.

Encourage collaboration and communication among healthcare providers to enhance the overall quality of care.

Refreezing:

Establish new protocols and standards for mental health safety and quality. Reinforce positive changes through ongoing training, monitoring, and feedback loops. Cultivate a culture that values and sustains the improvements made, ensuring continuous commitment to safety and quality in mental health care (Brallier et al., 2019). These types of infrastructure enhancements help mitigate common communication breakdowns like unclear care transition plans, inadequate problem awareness among community partners, and poor information relay across settings (Burgener, 2020). Shared EHR access also allows all parties to remotely edit or evaluate case details in real-time (Schimpf et al., 2019). Regularly scheduled meetings also promote open communication, group awareness, and clear follow-up tasks, all of which facilitate direct shared decision-making (Janssen et al., 2018). Therefore, it can be said that implementing such frameworks improves continuity of care and reduces the likelihood of critical information being overlooked or inaccessible to involved healthcare personnel. It ensures a more unified approach to patient care, enabling prompt interventions and individualized treatment catered to each patient's need (Burgener, 2020).

Conclusion

Throughout the study, a critical investigation has been conducted about Gary's patient safety incident where several healthcare flaws are found that contributed to his terrible outcome. Failures in risk assessment resulting from insufficient collection of history missed opportunities to gain a more thorough picture of Gary's condition throughout time. Another significant gap that made him vulnerable during the precarious post-discharge time was his early discharge without the creation of follow-up care plans (Guttman et al., 2021). Finally, Gary's grieving received no psychological care, indicating a failure to address the cultural and emotional issues influencing his mental health (Mukdarut et al., 2017).

In terms of human factors, communication breakdowns among providers hampered coordinated and integrated care delivery (Rustad et al., 2017). While the lack of engagement with Darren meant missed opportunities to obtain potentially critical additional details (Guttman et al., 2021). Clinical gaps in cultural competency hampered therapeutic relationships and compassionate treatment as well (Burgener, 2020). By overlooking Gary's profound grief, clinicians failed to acknowledge a significant aspect of his internal emotional landscape.

The recommendations focused on creating standardized mechanisms for acquiring collateral histories and improving interdisciplinary communication channels (Chang et al., 2020). Another essential component of closing knowledge gaps is integrating cultural competence training (Sheehan et al., 2022). Formalizing follow-up care plans that include community-based support and ongoing monitoring is also essential for stable discharges from hospitals (Janssen et al., 2018). Overall, the investigation into Gary's case revealed potential for mental health systems to improve evaluation thoroughness, communication procedures, cultural sensitivity, discharge planning, and continuity of care. Addressing these areas will be integral for providing individualized, holistic and supportive care catered to patients' multifaceted needs.

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