Itemizing Patient Safety Events in a New Children's Mental Health Hospital

Poster #: 44
Session/Time: A
Author: Hayden Cottle
Mentor: John Harrington, MD
Co-Investigator(s): 1. Maya Rao,  EVMS MD Program Student  2. Yvette Conyers R.N., M.S.N., CHKD Quality & Patient Safety  3. Turaj Vazifedan, D.H.Sc., CHKD Department of Pediatrics
Research Type: Clinical Research

Abstract

Introduction: Patient safety is one of the most important aspects of care management in healthcare. While substantial efforts have been made to improve patient safety in most facilities, in-patient pediatric mental health represents an area with unique challenges that require consideration. In October 2022, the Children's Hospital of The King's Daughters (CHKD) opened an in-patient pediatric mental health facility known as the Children's Pavilion (CP). The aim of this study was to gain a clearer understanding of the types of safety events that occurred within the first 17 months of operation at the CP.

Methods: All safety events for the CHKD event reporter (VERGE) were tabulated with duplicate and non-patient events subtracted. Events were then divided into three broad categories: behavioral, care management, and patient protection. These categories were further divided into more specific subcategories such as assault, medical events, and facilities issues. Data on the use of restraint and patient demographics (race, ethnicity, age, and biological sex) were also collected. Descriptive statistics were performed to summarize the distribution of events.

Results: 959 safety events were obtained from the CHKD event reporter (VERGE) and filtered to exclude duplicate events and those unrelated to patient safety. The remaining 772 events were then categorized into three broad groups, based on their respective descriptions: behavioral (BE), care management (CM), and patient protection (PP). Preliminary results show that BE were most common at 58% of all events, while CM and PP comprised 20% and 22%, respectively. Among BE, assaults on staff were most common (70%), followed by assaults on other patients (16%). For CM, medication events were most frequent (36%), followed by staff communication issues and patient relations (both 19%). In PP, contraband events were most common (34%), followed by facilities issues (25%), and self-harm (11%). 209 events involved the use of some form of restraint.

Conclusion: Preliminary findings suggest that behavioral events are the most common safety events at the CP. These results underscore the urgent need for safety measures to protect both staff and patients from violence. Future research should focus on identifying effective strategies to reduce behavioral events in these settings.