Patient safety rose in prominence in American medical thinking with the
publication a decade ago of "To Err Is Human," the Institute of
Medicine's (IOM) report estimating that tens of thousands of people die every
year in American hospitals due to preventable medical errors.
Now APA has published a 33-page handbook that addresses ways to develop and
integrate systems to reduce or prevent six critical events: suicide,
aggression, falls, elopement, medical comorbidities, and drug or medication
errors. Each chapter provides examples of unsafe care along with discussions
of what went wrong and how to prevent
The publication is an APA resource document prepared by the Committee on
Patient Safety and approved by the Council on Quality Care and the Joint
Reference Committee in June 2008. It can be downloaded free from the Web site
"We wanted to place the idea of patient safety directly in the hands
of working psychiatrists," said Alfred Herzog, M.D., medical director of
the professional programs at Hartford Hospital in Connecticut, in an
interview. Herzog was co-editor of the publication with Geetha Jayaram, M.D.,
M.B.A., an associate professor of psychiatry at the Johns Hopkins Hospital and
in its Department of Health Policy and Management.
"It had to be practical, useful, concise, and readily
available," said Herzog.
Like the rest of the patient-safety movement, the APA handbook emphasizes a
shift away from blaming medical professionals for mistakes and toward creating
systems that produce safe practices, wrote the editors.
"The likelihood that an individual will commit an error is far
greater in systems that are poorly organized and that have weak procedures and
regulations," they said. "A good staff member cannot combat a bad
The systemic approach has produced progress since the IOM report came out,
said patient-safety expert Lucian Leape, M.D., an adjunct professor of health
policy in the Department of Health Policy and Management at the Harvard School
of Public Health. Leape was a member of the IOM panel that produced the
"There's been a tremendous increase in activity, concern, and action
and a real improvement in safety," said Leape, in an interview."
The most important new development is the movement away from procedural
guidance to teamwork and relationships. This is hard for doctors, because they
train as individuals, not as team members.
The mistakes in medical specialties where practice involves more
procedures, preventing egregious errors like operating on the wrong leg have
been addressed with such protocols. Not surprisingly, the pattern is different
in psychiatry. True, a medication error is a medication error. Messy
handwriting or an added or missing zero on a prescription can confuse a
physician, pharmacist, nurse, or patient.
"Patient safety in psychiatry is more of a cognitive-awareness
process than a procedural process," said Herzog. "The psychiatrist
must ask, 'What information do I need, and what steps do I take to assume
safety with this patient?' The human interaction is critical."
Psychiatry may be less procedurally oriented than orthopedic surgery but
can still benefit from many of these safety ideas, said Leape. A patient using
several medications at once must be carefully managed to avoid interactions or
overmedication. Psychiatrists, even those who do not work primarily in
hospitals, are often part of treatment teams. In the course of treating one
patient, they may interact with psychologists, social workers, internists,
members of patients' families, as well as patients themselves.
Safety in psychiatry also means doing things more than
once—constantly reassessing risks while interacting with the patient,
said Herzog. "Making sure you minimize risk is more difficult with
The APA handbook uses patient vignettes delineating cases in which existing
safeguards failed. The text discusses each case briefly, analyzing the
failures, while adjacent tables list risk or protective factors, and
summarizes steps needed to minimize that particular danger.
The document draws on existing knowledge, said Herzog. "This is not
intended as original research, but rather serves as a summarizing and
If one thread runs through the document, it is communication. Psychiatrists
need to communicate closely and continuously with other members of the
treating team, as well as with patients and their families, as Leape
"SAFE MD: Practical Applications and Approaches to Safe
Psychiatric Practice" is posted at<http://psych.org/safemd>.▪