Self-Harm During Constant Observation

Harm Range: No detectable harm to moderate temporary harm.

According to the Children’s Hospital Association Pediatric Health Information System® (PHIS) database, suicidal ideation, attempts, and self-harm are now the most common mental health conditions seen in children’s hospitals’ emergency departments.¹

Behavioral health patients who pose a safety risk to themselves or others require one-on-one constant observation. But complex and demanding health care environments may allow opportunities for patients to attempt self-harm despite observation. Care team vigilance and communication are key to maintaining safe patient care.

Contributing factors may include:

• Inadequate monitoring or lack of continuous visualization of patients
• Failure to effectively search the patient and their belongings upon admission and as needed
• Patient access to common items that may not be recognized as risks for self-harm
• Unclear guidelines or policies related to patients at risk for suicide who are presenting for non-behavioral health diagnoses
• Difficulty implementing safety practices while also offering patient privacy
• Distraction of team members responsible for constant supervision
• Insufficient communication between teams related to the care of the patient
• Uncertainty of the constant observer responsibilities and when to escalate concerns

Patients who self-harm while under constant observation may require additional procedures, treatment, or transfer of care with utilization of extra staff and resources.

Recommendations

• Develop a clear policy and expectations for screening at-risk patients on admission and as needed for safety concerns
• Outline specific criteria defining which patients require screening and searching and at what intervals. Consider universal screening of suicide risk in emergency departments for patients greater than 12 years old.²
• Create a checklist with clear steps to be followed when conducting searches.
• Consider security wanding at-risk patients or those who have a previous history of self-harm behaviors.
• Review common items that may be used in the patient’s care or introduced into their environment that may present a risk for self-harm.
• Evaluate and refine the constant observer role and responsibilities to consider human factor components.³
  • To counter fatigue, consider:
    • Implementing shorter, more frequent breaks
    • Creating constant observer partners to rotate between two patients every 30 minutes
    • Employing constant observer patient changes every 30 minutes
    Train constant observers to perform “systematic scanning” of the environment, occasionally changing the scanning direction
    • Utilize a continuous “systematic scanning checklist” beginning with the patient and broadening the focus to the surrounding environment
  Consider offering high-fidelity simulation education to increase confidence and provide guidance and clarity of constant observer role
  • Decision frameworks such as the OODA loop can improve decision-making proficiency^3,4
• Highlight patients’ previous behavioral health visits or diagnoses in the EMR to promote awareness
• Encourage strong team communication through rounding, scripting, escalation processes, and huddles

Resources

• Addressing Pediatric Suicide

References

• “Addressing Pediatric Suicide.” Children’s Hospital Association
• Do, Lauren, et al. "Universal suicidality screening in a pediatric emergency department to Improve Mental Health Safety Risk." Journal of Emergency Nursing
• Human Factors Transforming Healthcare
• OODA loop | Military History and Science | Research Starters | EBSCO Research

Acknowledgments

We thank Human Factors Transforming Healthcare for contributing to and reviewing this Safety Watch.

This safety watch is approved for general distribution to improve pediatric safety and reduce patient harm. This safety watch meets the standards of non-identification in accordance with 3.212 of the Patient Safety Quality Improvement Act (PSQIA) and is a permissible disclosure by Child Health PSO. In accordance with our Terms of Use and Code of Conduct, this material cannot be used for any commercial transactions that are unrelated to the original intent of Child Health PSO Patient Safety Action watch.