Summary
This investigation by the Health Services Safety Investigations Body (HSSIB) considers improvements that can be made to patient safety in relation to the use of continuous observation with adult patients in acute hospital wards who are at risk of self-harm. For its reference case, it looks at the case of a patient who self-harmed when receiving care at a high dependency unit while two members of staff were continuously observing her.
Content
Findings of this report included:
- There is a lack of evidence about how to optimise the safety and quality of continuous observations of adults, or when it is most appropriate to use this intervention.
- There are limited national guidelines and standards on when and how continuous observation should be carried out, and a lack of clear guidance on the training needs and competencies of staff doing this.
- Formal processes are often not in place to anticipate and support effective collaborative working where mental health staff work alongside physical health staff in an acute hospital to provide care to a patient at risk of self-harm.
For local-level learning, the report includes a series of prompts that are designed to help acute (physical) hospital and mental healthcare providers to work in collaboration whilst continuously observing a patient at risk of self-harm. It also includes a series of prompts for healthcare providers to consider how they can support staff caring for these patients.
In this report HSSIB makes the following safety recommendations:
- The Department of Health and Social Care, through the National Institute for Health and Care Research (NIHR), assesses the priority, feasibility and impact of future research into the efficacy and acceptability of continuous observation of mentally unwell adult patients. The research should take into account different care settings in which continuous observation may take place (including physical and mental health hospitals) and the different staff groups involved in carrying it out.
- NHS England, working with relevant stakeholders, produces national guidance for staff undertaking continuous observation of mentally unwell adult patients, along with a training and competency framework to provide staff with the necessary skills for this intervention in different care settings (including physical and mental health hospitals). Development of this guidance should include engagement with human factors principles to understand the complexities of the task of continuous observation and the environments in which it may take place.
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