Abstract

Patient safety issues are important due to patients cognitive declines and physical inactivity in mental institutions. A Root cause analysis is applied to analyse the deaths among psychiatric patients admitted in ward of a teaching hospital with an aim to study various patient safety factors contributing to the deaths for the last 2 years. It is situated a little distance from the main inpatient building of the hospital. Case records of all deaths (four in all) were obtained and root cause analysis was carried out, both from examination of the case records as well as the departmental death review. About 500 patients admitted every year accompanied by a relative and four deaths reported in last 2 years (2008–2009) that is, 0.8%. Three males and one female reported death. The cases were diagnosed as Bipolar Disorder current episode mania, Alcohol dependence, Grief/Psychosis, Post head injury psychosis with causes of deaths were aspiration pneumonitis, alcohol poisoning, aspiration and irreversible shock with hypothermia. The Root cause analysis of organisational/management, work environmental factors, team/staff, patients factors, task factors revealed the specific and general contributory factors were distance of the ward from the rest of the hospital, poor communication among staff and responses of the hospital emergency teams to SOS from Psychiatry and poor recognition of serious physical factors/symptoms. A planned future intervention patient safety was recommended suggesting the availability of heater and blankets, timely transfer, implementation of SOPs for patients work up immediately after admission and proper team coordination for patients referral.