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Fröding, E. & Ros, A. (2023). A cultural shift is needed to improve patient safety: En kulturförändring behövs för att öka patientsäkerheten. Läkartidningen, 120(7 August)
Open this publication in new window or tab >>A cultural shift is needed to improve patient safety: En kulturförändring behövs för att öka patientsäkerheten
2023 (Swedish)In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 120, no 7 AugustArticle in journal (Refereed) Published
Abstract [en]

In a recently published thesis, we propose a cultural shift in the assessment of suicide as an incident of severe patient harm, from a focus on errors and an often speculative avoidability, to healthcare's ability of risk management over time. Patient safety work needs to change in line with the development of knowledge in patient safety. This means a cultural change in the view of patient safety, with a clearer focus on healthcare's abilities in risk management and learning. Legislation and regulations regarding healthcare and the supervisory authority need to support this cultural change in assessment and investigations of patient harm.  A shift from a focus on errors and deviations to quality and positive outcomes of care, proactive patient safety work, risk management, patient safety culture and management commitment is needed.

Place, publisher, year, edition, pages
Läkartidningen Förlag AB, 2023
Keywords
Delivery of Health Care, Humans, Patient Safety, Safety Management, Suicide, health care delivery, human, safety
National Category
Nursing Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-62250 (URN)37548446 (PubMedID)2-s2.0-85166762963 (Scopus ID)POA;;898078 (Local ID)POA;;898078 (Archive number)POA;;898078 (OAI)
Available from: 2023-08-22 Created: 2023-08-22 Last updated: 2023-08-25Bibliographically approved
Probert-Lindstrom, S., Vaez, M., Fröding, E., Ehnvall, A., Sellin, T., Ambrus, L., . . . Westrin, A. (2023). Utilization of psychiatric services prior to suicide - a retrospective comparison of users with and without previous suicide attempts. Archives of Suicide Research, 27(2), 401-414
Open this publication in new window or tab >>Utilization of psychiatric services prior to suicide - a retrospective comparison of users with and without previous suicide attempts
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2023 (English)In: Archives of Suicide Research, ISSN 1381-1118, E-ISSN 1543-6136, Vol. 27, no 2, p. 401-414Article in journal (Refereed) Published
Abstract [en]

Introduction

The aim was to investigate psychiatric health care utilization two years before death by suicide among individuals with previous suicide attempts (PSA) compared with those without (NSA).

Method

A retrospective population-based cohort study was conducted including 484 individuals who died by suicide in Sweden in 2015 and were in contact with psychiatric services within the two years preceding death, identified through the Cause of Death register. Data on psychiatric health care two years before death, including suicide attempts according to notes in the medical record was used. Associations between having at least one PSA vs. NSA and health care utilization were estimated as odds ratios (OR) with 95% confidence intervals (CI) by logistic regression analyses.

Results

Of the 484 individuals included, 51% had PSA. Those with PSA were more likely than NSA to have received a psychiatric diagnosis [OR 1.96 (CI 95% 1.17-3.30)], to have ongoing psychotropic medication [OR 1.96 (CI 95% 1.15-3.36)] and to have been absent from appointments during the last three months [1.97 (1.25-3.13)]. In addition, elevated suicide risk was more often noted in the psychiatric case records of those with a PSA than those without [OR 2.17 (CI 95% 1.24-3.79)].

Conclusion

The results underline the importance of improved suicide risk assessment as well as thorough diagnostic assessment and when indicated, psychiatric treatment as suicide preventive interventions regardless of PSA. Furthermore, the larger proportion of absence from appointments in individuals with PSA may indicate a need of improved alliance between psychiatric care providers and individuals with PSA.

Place, publisher, year, edition, pages
Taylor & Francis, 2023
Keywords
Medical records, psychiatric health care utilization, suicide, suicide attempts
National Category
Psychiatry
Identifiers
urn:nbn:se:hj:diva-55402 (URN)10.1080/13811118.2021.2006101 (DOI)000722514100001 ()34821208 (PubMedID)2-s2.0-85120822238 (Scopus ID)HOA;;785490 (Local ID)HOA;;785490 (Archive number)HOA;;785490 (OAI)
Available from: 2021-12-20 Created: 2021-12-20 Last updated: 2023-08-29Bibliographically approved
Bergqvist, E., Probert-Lindstrom, S., Fröding, E., Palmqvist-Oberg, N., Ehnvall, A., Sunnqvist, C., . . . Westrin, A. (2022). Health care utilisation two years prior to suicide in Sweden: a retrospective explorative study based on medical records. BMC Health Services Research, 22(1), Article ID 664.
Open this publication in new window or tab >>Health care utilisation two years prior to suicide in Sweden: a retrospective explorative study based on medical records
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2022 (English)In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 22, no 1, article id 664Article in journal (Refereed) Published
Abstract [en]

Objective

Previous literature has suggested that identifying putative differences in health care seeking patterns before death by suicide depending on age and gender may facilitate more targeted suicide preventive approaches. The aim of this study is to map health care utilisation among individuals in the two years prior to suicide in Sweden in 2015 and to examine possible age and gender differences.

Methods

Design: A retrospective explorative study with a medical record review covering the two years preceding suicide. Setting: All health care units located in 20 of Sweden's 21 regions. Participants: All individuals residing in participating regions who died by suicide during 2015 (n = 949).

Results

Almost 74% were in contact with a health care provider during the 3 months prior to suicide, and 60% within 4 weeks. Overall health care utilisation during the last month of life did not differ between age groups. However, a higher proportion of younger individuals (< 65 years) were in contact with psychiatric services, and a higher proportion of older individuals (≥ 65 years) were in contact with primary and specialised somatic health care. The proportion of women with any type of health care contact during the observation period was larger than the corresponding proportion of men, although no gender difference was found among primary and specialised somatic health care users within four weeks and three months respectively prior to suicide.

Conclusion

Care utilisation before suicide varied by gender and age. Female suicide decedents seem to utilise health care to a larger extent than male decedents in the two years preceding death, except for the non-psychiatric services in closer proximity to death. Older adults seem to predominantly use non-psychiatric services, while younger individuals seek psychiatric services to a larger extent.

Place, publisher, year, edition, pages
Springer Nature, 2022
Keywords
Suicide, Health services, Health care utilisation, Medical records
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-56907 (URN)10.1186/s12913-022-08044-9 (DOI)000796955200002 ()35581647 (PubMedID)GOA;;816020 (Local ID)GOA;;816020 (Archive number)GOA;;816020 (OAI)
Funder
Swedish National Board of Health and WelfareRegion Halland
Available from: 2022-06-08 Created: 2022-06-08 Last updated: 2022-10-27Bibliographically approved
Fröding, E. (2022). Patient safety and suicide: learning in theory and practice from investigations of suicide as patient harm. (Doctoral dissertation). Jönköping: Jönköping University, School of Health and Welfare
Open this publication in new window or tab >>Patient safety and suicide: learning in theory and practice from investigations of suicide as patient harm
2022 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Suicide is a global public health challenge, around 700 000 people die from suicide every year. A large proportion was in contact with healthcare close in time before death, suggesting healthcare to be an important resource in the work with prevention of suicide.

The overall aim of this thesis was to increase the knowledge and understanding of suicide as an incident of patient harm, and to find possibilities of changes in the approach to suicide investigations which could contribute to increased learning and improve suicide prevention in healthcare.

Four studies were performed: in the first two studies we reviewed investigations of healthcare performed of suicide cases reported to the supervisory authority as patient harm. Study III was a scoping narrative literature review of the problems with the current approaches to investigations of suicide as patient harm and possible changes for improvement. Study IV was an interview study in which I explored the requirements for valuable investigations of suicide from the views of persons with lived experience of suicidality and professionals. All studies were performed in a Swedish context.

The majority of suicides reported as incidents of patient harm were reported by a psychiatry healthcare provider. Most suicides occurred shortly after the last contact with healthcare and during outpatient care. Demographically, these cases were representative compared to the suicide cases in the entire population.

As incidents of patient harm, suicides differ from most other kinds of reported patient harm in some ways. Only a small proportion occurs in hospitals, most occur in the home of the patient without any witnesses or staff around. Suicide is an act performed by the patient himself/herself and is usually the final outcome of the complex interplay of several different variables with different impacts in different contexts, varying over time and between individuals.

It was found that the adaptation of the investigations to the requirements of the supervisory authority contributed to the fact that the learning from the healthcare’s investigations of suicide has levelled off, the same shortcomings and actions were reported over time. The investigations were performed with a strict healthcare provider perspective, with focus on the last contact with the patient, routines, and what went wrong. This resulted in suggested measures for improvement at an organizational micro level without organizational sustainability over time and with a risk to not address organizational system deficiencies.

The investigations of suicide as potential patient harm should integrate current knowledge in suicidology and patient safety to enable learning and insights valuable for healthcare improvement. This include a holistic perspective of the patient’s situation, analysis of a longer time period and factors of importance for suicidality, suicide prevention, and patient safety, professionalization of the investigations, analyses across organizational boundaries, and focus on learning. A framework to guide this analysis is suggested in this thesis.

The development of knowledge in the science fields of patient safety and suicidology imply the need for a cultural shift in the understanding of suicide as an incident of patient harm. Instead of making a difficult and often to some extent speculative assessment if a suicide had been prevented if other actions had been performed in the contacts with healthcare, and therefore should be investigated and reported as a severe patient harm, or not, the focus in the analyses should be on risk management over time. I propose a framework with factors of importance for a safe healthcare at suicidality to guide this analysis.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare, 2022. p. 152
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 123
Keywords
Suicide, Suicide prevention, Patient safety, Patient harm, Investigation, Improvement
National Category
Psychiatry
Identifiers
urn:nbn:se:hj:diva-58726 (URN)978-91-88669-22-3 (ISBN)
Public defence
2022-12-09, Qulturum, Länssjukhuset Ryhov,, Jönköping, 13:00 (English)
Opponent
Supervisors
Available from: 2022-10-27 Created: 2022-10-27 Last updated: 2022-10-27Bibliographically approved
Fröding, E., Mellqvist, J. & Saric, M. (2022). Proaktivt patientsäkerhetsarbete i den psykiatriska slutenvården [Proactive work with patient safety in psychiatry, Patient safety in Real time in Psychiatry]. Läkartidningen, 119(July)
Open this publication in new window or tab >>Proaktivt patientsäkerhetsarbete i den psykiatriska slutenvården [Proactive work with patient safety in psychiatry, Patient safety in Real time in Psychiatry]
2022 (Swedish)In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 119, no JulyArticle in journal (Refereed) Published
Abstract [en]

Traditionally, work with patient safety has mainly been focused on examining and learning from incidents retrospectively. Proactive methods to support and evaluate patient safety as work-as-done in real time are needed. Patient safety in Real time in Psychiatry (PiRiP), combining systematic reviews of inpatient records and interviews with inpatients and staff, can be such a method. We have evolved and tested this approach in psychiatric wards in Region Jönköping County and Region Västernorrland. We found that discussion and reflection with staff about the patients' views of care and treatment, observed strengths, risks and possibilities of improvement were of value to increase awareness and knowledge of how performance of daily work relates to patient safety. PiRiP adheres to the basic principles of patient safety as described in the national action plan for patient safety.

Abstract [sv]

Metoder behövs för att värdera och stödja det proaktiva patientsäkerhetsarbetet i den patientnära vården. Patientsäkerhet i realtid i psykiatrin (PiRiP) kan vara en sådan metod.

PiRiP innefattar journalgranskning av pågående vårdtillfällen, samtal med patienter och personal samt återkoppling och diskussion av resultat.

Diskussion med personal kring patienternas synpunkter, iakttagna risker och styrkor i den patientnära vården kan vara värdefull för att öka kunskap och medveten­heten om betydelsen av det egna arbetssättet för patientsäkerheten.

PiRiP inkluderar grundläggande förutsättningar för patientsäkerhet beskrivna i Socialstyrelsens nationella handlingsplan för patientsäkerhet.

Place, publisher, year, edition, pages
Sveriges Läkarförbund, 2022
Keywords
Humans, Inpatients, Patient Safety, Psychiatry, Retrospective Studies, hospital patient, human, psychology, retrospective study
National Category
Psychiatry Nursing
Identifiers
urn:nbn:se:hj:diva-58159 (URN)35875911 (PubMedID)2-s2.0-85134979695 (Scopus ID)POA;;824532 (Local ID)POA;;824532 (Archive number)POA;;824532 (OAI)
Available from: 2022-08-10 Created: 2022-08-10 Last updated: 2023-01-24Bibliographically approved
Fröding, E., Vincent, C., Andersson-Gäre, B., Westrin, Å. & Ros, A. (2022). Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention. Archives of Suicide Research
Open this publication in new window or tab >>Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention
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2022 (English)In: Archives of Suicide Research, ISSN 1381-1118, E-ISSN 1543-6136Article, review/survey (Refereed) Epub ahead of print
Abstract [en]

OBJECTIVE: The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward.

METHODS: Narrative literature review.

RESULTS: Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety.

CONCLUSIONS: There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.

HIGHLIGHTS

  • There are weaknesses in the current approaches to investigations of suicide.
  • A paradigm shift in investigations is needed to contribute to a better understanding of suicide.
  • New knowledge of suicidal behavior, prevention, and patient safety must be applied.
Place, publisher, year, edition, pages
Taylor & Francis, 2022
Keywords
Improvement, investigation, patient harm, patient safety, suicide, suicide prevention
National Category
Psychiatry
Identifiers
urn:nbn:se:hj:diva-58722 (URN)10.1080/13811118.2022.2133652 (DOI)000870151100001 ()36259504 (PubMedID)2-s2.0-85140124056 (Scopus ID)HOA;intsam;839465 (Local ID)HOA;intsam;839465 (Archive number)HOA;intsam;839465 (OAI)
Funder
Futurum - Academy for Health and Care, Jönköping County Council, Sweden
Available from: 2022-10-27 Created: 2022-10-27 Last updated: 2023-06-30
Fröding, E., Andersson-Gäre, B., Westrin, Å. & Ros, A. (2021). Suicide as an incident of severe patient harm: A retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective. BMJ Open, 11(3), Article ID e044068.
Open this publication in new window or tab >>Suicide as an incident of severe patient harm: A retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective
2021 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 11, no 3, article id e044068Article in journal (Refereed) Published
Abstract [en]

Objectives

To explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed.

Design and settings

Retrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide.

Participants

Cohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316).

Primary and secondary outcome measures

Demographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcare and actions were categorised by using a coding scheme, analysed per individual and aggregated per cohort. Separate notes were made when a deficiency or action was related to a healthcare-service routine.

Results

The investigations largely adopted a microsystem perspective, focusing on final patient contact, throughout the overall study period. Updating existing or developing new routines as well as educational actions were increasingly proposed over time, while sharing conclusions across departments rarely was recommended.

Conclusions

The mandatory reporting of suicides as potential cases of patient harm was shown to be restricted to information transfer between healthcare providers and the supervisory authority, rather than fostering participative improvement of patient safety for suicidal patients.

The similarity in outcomes across the cohorts, regardless of changes in legislation, suggests that the investigations were adapted to suit the structure of the authority’s reports rather than the specific incident type, and that no new service improvements or lessons are being identified.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2021
Keywords
health & safety, quality in health care, risk management, suicide & self-harm
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-52067 (URN)10.1136/bmjopen-2020-044068 (DOI)000627818900005 ()33687954 (PubMedID)2-s2.0-85102366241 (Scopus ID)GOA;;730407 (Local ID)GOA;;730407 (Archive number)GOA;;730407 (OAI)
Funder
Futurum - Academy for Health and Care, Jönköping County Council, SwedenPublic Health Agency of Sweden
Available from: 2021-03-22 Created: 2021-03-22 Last updated: 2023-08-28Bibliographically approved
Fröding, E., Edvinsson, J., Mellqvist, J. & Ros, A. (2020). PIR – patientsäkerhet i realtid – lämpade sig väl under pandemin. Läkartidningen, 117(48), 1587-1589
Open this publication in new window or tab >>PIR – patientsäkerhet i realtid – lämpade sig väl under pandemin
2020 (Swedish)In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 117, no 48, p. 1587-1589Article in journal (Refereed) Published
Abstract [en]

The adaptation of the healthcare needed in the covid-19 pandemic poses challenges to patient safety. Proactive patient safety work must continue even under conditions such as a pandemic. Methods are needed that assess and support patient safety as the work is carried out. Patient safety in real time appears to be such a useful method in which patient record review to identify patient harm is combined with interviews with patients and healthcare staff. The method was used in wards and intensive care units (ICU) for covid-19 patients in Region Jönköping County. Patient harm was found in ICU care. Patients were overall satisfied with the care, and in the interviews with healthcare staff areas for improvement were identified. Valid indicators for patient record review to evaluate patient harm in covid-19 need to be developed. To judge if patient harm in care of a Covid-19 is avoidable or not is difficult since the level of knowledge and treatment principles in the disease develops very fast.

Place, publisher, year, edition, pages
Läkartidningen Förlag AB, 2020
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-51144 (URN)2-s2.0-85096949138 (Scopus ID)POA HHJ 2020 (Local ID)POA HHJ 2020 (Archive number)POA HHJ 2020 (OAI)
Available from: 2020-12-07 Created: 2020-12-07 Last updated: 2021-03-01Bibliographically approved
Roos af Hjelmsäter, E., Ros, A., Andersson-Gäre, B. & Westrin, Å. (2019). Deficiencies in healthcare prior to suicide and actions to deal with them: A retrospective study of investigations after suicide in Swedish healthcare. BMJ Open, 9(12), Article ID e032290.
Open this publication in new window or tab >>Deficiencies in healthcare prior to suicide and actions to deal with them: A retrospective study of investigations after suicide in Swedish healthcare
2019 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 9, no 12, article id e032290Article in journal (Refereed) Published
Abstract [en]

Objectives

The overall aim of this study was to aggregate the conclusions of all investigations conducted after suicides reported to the supervisory authority in Sweden in 2015, and to identify deficiencies in healthcare found in these investigations; the actions proposed to deal with the deficiencies; the level of the organisational hierarchy (micro-meso-macro) in which the deficiencies and actions were situated; and outcomes of the supervisory authority's decisions.

Design and setting

This is a retrospective study of all reports from Swedish primary and secondary healthcare after suicide to the regulatory authority in Sweden in 2015.

Results

In 55% (n=240) of cases, healthcare providers reported healthcare deficiencies that contributed to suicide; these deficiencies were primarily in 'suicide risk assessment' and 'treatment'. Actions aimed at preventing new suicides were proposed in 80% of cases (n=347). By far, the most frequent actions were 'education and competence', present in 52% of cases (n=227) and did not much correspond with identified deficiencies. Sixty-five per cent of the deficiencies and actions were at microlevel, while the remainders were at mesolevel. In 65% (n=284) of cases, the supervisory authority approved the investigation without further requirements.

Conclusions

The most common identified deficiencies were related to care in the immediate interface between patient and staff. Actions proposed to prevent new suicides were centred on single educational interventions without distinctive sustainable effects in the organisations and usually did not correspond with the identified deficiencies. Future research should examine if application of a framework based on knowledge of the suicide process, suicide prevention strategies and patient safety would enable more sophisticated investigations that could facilitate progress on suicide prevention. 

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2019
Keywords
adult psychiatry, health & safety, quality in health care, risk management, suicide & self-harm
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-47208 (URN)10.1136/bmjopen-2019-032290 (DOI)000512773400161 ()31831542 (PubMedID)2-s2.0-85076422244 (Scopus ID)GOA HHJ 2019 (Local ID)GOA HHJ 2019 (Archive number)GOA HHJ 2019 (OAI)
Funder
Futurum - Academy for Health and Care, Jönköping County Council, Sweden
Available from: 2020-01-02 Created: 2020-01-02 Last updated: 2023-08-28Bibliographically approved
Fröding, E., Vincent, C., Andersson-Gäre, B., Westrin, Å. & Ros, A.Requirements for effective investigation and learning after suicide: The views of persons with lived experience and professionals.
Open this publication in new window or tab >>Requirements for effective investigation and learning after suicide: The views of persons with lived experience and professionals
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(English)Manuscript (preprint) (Other academic)
National Category
Psychiatry
Identifiers
urn:nbn:se:hj:diva-58724 (URN)
Available from: 2022-10-27 Created: 2022-10-27 Last updated: 2022-10-27
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-9095-1322

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