Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs–Contracted Community Care

Author:

Riblet Natalie B12ORCID,Soncrant Christina3,Mills Peter34,Yackel Edward E3

Affiliation:

1. Mental Health Service Line, Veterans Affairs Medical Center , White River Junction, VT 05009, USA

2. Department of Psychiatry and Dartmouth Institute, Geisel School of Medicine, Dartmouth College , Hanover, NH 03755, USA

3. VA National Center for Patient Safety , Ann Arbor, MI 48106, USA

4. Department of Psychiatry, Geisel School of Medicine, Dartmouth College , Hanover, NH 03755, USA

Abstract

ABSTRACT Introduction Veteran patients have access to a broad range of health care services in the Veterans’ Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)–contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. Materials and Methods A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. Results Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care–related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. Conclusions It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.

Funder

VA National Center for Patient Safety Center of Inquiry Program, Ann Arbor, MI

U.S. Department of Veterans Affairs

Publisher

Oxford University Press (OUP)

Subject

Public Health, Environmental and Occupational Health,General Medicine

Reference38 articles.

1. The VA MISSION Act and community care for veterans: what every community GI doc needs to know;Adams;Am J Gastroenterol,2019

2. Addressing suicide in the veteran population: engaging a public health approach;Carroll;Front Psychiatry,2020

3. Understanding VA’s use of and relationships with community care providers under the MISSION Act;Mattocks;Med Care,2021

4. Fact sheet: how to become a VA community provider;Veterans Health Administration, Office of Community Care

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