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P26 - A Process for Keeping the Mental Behavioral Health Patient Safe on Medical-Surgical Units

Purpose: To improve implementation of safety measures for mental behavioral health patients on medical-surgical units. To develop new policies and procedures reflecting the new Joint Commission (JC) standards related to patient safety of these patients.

Mental and behavioral patients are frequently placed on medical-surgical units for treatment of medical problems. As a result, to increase awareness of the Joint Commission (JC) standards related to patient safety. Our organization formed a task force to review best practices to address the safety of this population.

Effective July 1, 2019, the Joint Commission rolled out new requirements in the National Patient Safety Goals (NPSG 15.01.01) to address suicide prevention. These goals were designed to improve the quality and safety of care of patients who are at high risk for suicide. Suicide is the 10th leading cause of death in the US. The safety goals and
requirements apply to patients admitted to psychiatric units, as well as psychiatric patients being evaluated or treated for psychiatric event requiring admittance to general hospital for medical reasons. These patients require a safe environment to minimize their potential for self-harm or harm to others.

Description: A lack of available mental health facilities capable of treating both physical and mental health emergencies exist. Care and maintaining safety of mental behavioral health patients on medical-surgical units, as well as emergency departments, present unique challenges. The most common mental health problems experienced by acute hospital inpatients are self-harm, depression, dementia, adjustment reactions, and abuse disorders. The balance of providing quality and safe mental health in these areas have been recognized by JC. Staff in acute hospitals have limited knowledge about legal processes for detaining mental health patients and mental health care. Medical-surgical staff are often unprepared to meet these patient’s needs and do not recognize potential items of harm in the environment.

A dedicated multidisciplinary team was established to develop processes to ensure safe environments and staff training. A literature review was conducted. JC guidelines on ligature risks and mitigation and environmental concerns were reviewed and considered in developing processes and policy for medical-surgical units.

Evaluation and outcome: Based on the information obtained mitigation plan with processes to help in preventing self-harm and harm to others, monitoring guidelines for high-risk patients were developed. Staff was educated on the processes, including training and assessments related to observations, care of patients with mental behavior diagnoses, and establishing a safe environment. A monitoring process was put in place to measure compliance to new guidelines and procedures.