2021_Book_TextbookOfPatientSafetyAndClin

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chemical constraint. Environmental restraint
(seclusion) refers to limiting the mobility of
patients to a specifically designed and securely
locked room. Physical/mechanical restraint refers
to the use of any technique to manually restrict
the free body movement of a person or any part
of the body. Mechanical restraint refers to the use
of appliances and devices like body vests,
multiple- point ligatures, blankets and bedside
rails to immobilize the patient. Chemical restraint
refers to the use of drugs to rapidly tranquillize or
sedate the patient. The drugs that are commonly
used for this practice include benzodiazepines
and antipsychotics [4].
Errors relating to restraint and seclusion primarily
result from the misuse of restraints or
holding techniques. Errors also result from failure
in monitoring the patients from using sharp
objects or cigarette lighter to relieve themselves
from the restraint. Also, patients with comorbid
illnesses like asthma, cocaine intoxication, cardiomyopathy,
pulmonary hypertension or coronary
artery disease are at an increased risk of
sudden death by restraint devices. Failure in documenting
and assessing these risk factors may
affect patient safety [25].
20.3.1.3 Suicide
Suicide is described as deliberate physical selfharm
leading to death [4]. Suicide attempts tend
to peak during early admission to psychiatric
institutes and soon after discharge [31]. As compared
to the genera; population, the risk of dying
by suicide while being admitted to a psychiatric
unit is much higher. An English study reported
that among the patients who died by suicide, 39%
were on agreed leave, 29% were absconding and
32% died in the ward [32]. Researchers have
demonstrated that despite using sophisticated
methods, it is impossible to predict suicide even
in high-risk patients completely [11].
The most common predictors of inpatient suicide
include a history of deliberate self-harm,
depressive symptoms upon admission, and a
diagnosis of schizophrenia [32]. The suicide incidences
in patients who are suffering from schizophrenia
are 10–13% [33]. The method of suicide
largely depends on the means that are available in
the wards and includes hanging, strangulation,
asphyxiation and cutting; among absconders the
methods include drowning, jumping from a
height, jumping in front of a vehicle and overdosing
[31]. A large-scale study reported no difference
in the risk of suicide in patients admitted to
wards with and without doors [32]. However, the
variables involved in suicide risk are multiple and
there are situations in which an inpatient unit
with closed doors is safer than a unit with open
doors. Also, a closed unit avoids the need for
nurses to spend time watching the door as
opposed to talking and interacting with patients.
However, there are situations in which a closed
unit increases anxiety and agitation, over the
feeling of being trapped, which might increase
suicide risk. What is clear is that a poor assessment
of suicide risk level and inadequate monitoring
of patients at risk of suicide invariably
leads to decreased safety [25].
20.3.2 Nondrug Medical Error
A. Cuomo et al.
These include omitted, incorrect or delayed tests
or procedures. They also include issues such as
excessively low level of monitoring or observation,
communication errors and failure to eliminate
environmental dangers [16]. The three main
categories of nondrug medical errors are errors
proximal to the elopement, errors proximal to
contraband and other errors [3].
20.3.2.1 Errors Contributing
to Elopement
Elopement is the unauthorized absence of a
patient from the psychiatric unit. Common reasons
for elopement include the feeling of being
trapped/confined, desire to use drugs or alcohol,
feeling to be cut off from family and friends,
boredom, being afraid of the other patients,
objection over taking medications and stigma
about being in a psychiatric unit. Involuntarily
admitted patients have a higher chance of eloping
from the psychiatric unit [34]. Elopement by
itself is not an error, but the use of unguarded
doors or windows may be considered as an error
which allows the patient to flee from the unit [3].