Preventing Serious Reportable and Sentinel Events Within Psychiatric Inpatient Settings—A Scoping Review

Abstract

Serious reportable and sentinel events are preventable events that cause death or serious injuries to patients. Such events within the field of psychiatry include abscondment, inpatient suicide, unexpected deaths, sexual assaults, and serious physical assaults. This review aimed to examine the contributing risk factors and preventive strategies of serious reportable or sentinel events. PRISMA for scoping reviews and the updated Arksey and O'Malley methodological framework for conducting scoping reviews guided the methodology of the review. Databases (CINAHL, Embase, PsycINFO, PubMed, ScienceDirect, and Scopus) were searched. Twenty-nine articles were included. The articles explored (1) inpatient suicide [n=18 (62.07%)]; (2) general adverse events [n=5 (17.24%)]; (3) serious assaults [n=2 (6.90%)]; (4) abscondment [n=2 (6.90%)]; and (5) inpatient sexual events [n=2 (6.90%)]. Preventive strategies were as follows: (1) suicide (means restriction, allocation of high‑risk patients to higher‑dependency wards, safe prescribing, psychiatrist review of high-risk patients around the clock); (2) unexpected death (routine medical review, prompt activation of the code blue team); and (3) sexual incidents (segregation of genders). Consistent preventive strategies common to all adverse events, including establishment and continual review of guidelines, optimal staffing, and training, a secured ward with surveillance and no blind spots, rigorous observation, individualized risk assessments, and supportive counseling to patients. Consistent factors were associated with varying serious reportable or sentinel events. These factors were associated with patient and ward profiles, management, staffing, training, observation, risk assessments, and treatment. Bolstering factors related to the prevention of these events can enhance patient safety and the provision of quality care for psychiatric inpatients.