Study Finds Deaths Are Averted By Over-the-Door Alarms! | Check Out The Study Here

A LOOK BACK:
WHY DO WE NEED OVER THE DOOR ALARMS IN OUR FACILITIES?
In a recent patient safety tip reporting on a VA patient safety study, the findings suggest that many death were likely averted by over-the-door alarms.  
This is amazing news.  That lives are being saved through the progression of safer built environments for patients in an inpatient setting.
WHERE DID IT ALL BEGIN? 
Years ago, the inpatient healthcare community realized the need to upgrade safety procedures and products for our behavioral health facilities, while maintaining the privacy and respect of our patients.  Since then, facility managers and health professionals have been spearheading the effort to recifiy this problem.
It all began with a tragic sucide at a VA Hospital.  This suicide was by a patient who used as an anchor the top of a corridor door to hang himself at a VA hospital.
The case was reported to the Joint Commission as a sentinel event and facility leaders completed an institutional disclosure with members of the patient’s family. The VA Office of the Inspector General  was called to formally investigate the case.
Because of the seriousness of this case and immediate need for resources, the VA system has produced many valuable resources on suicide prevention that we now use in hospitals world-wide.

VA researchers undertook a study of all VA medical centers having behavioral health units. Mills et al. (Mills 2020) searched VHA databases for reports of suicide deaths and attempts on inpatient mental health units from January 2008 (when VHA began using over-the-door alarms) to June 2019.

Of the 127 RCA and safety reports of hanging on a door, 44 (34.6%) cases involved an over-the-door alarm. And in every case involving an over-the-door alarm, the patient did not die. In 2 cases the patients were contemplating hanging but did not because they were aware of the over-the-door alarms.

The authors conclude that, though the association is not proof, the findings suggest that many deaths were likely averted by over-the-door alarms.

We summarized lessons learned from that case:
• Use a tool like the VA Mental Health Environment of Care Checklist (MHEOCC) to guide your environment of care rounds on your behavioral health units.
• Make sure all relevant staff are appropriately trained on the MHEOCC.
• Strongly consider use of over-the-door alarms on your corridor doors on behavioral health units.
• Make sure your responsible staff understand their role in your 15-minute (or other designated interval) observations and that they are not multi-tasking during those responsibilities. Audit compliance with these protocols.
• When your security cameras malfunction for any reason, make sure the reasons for such malfunctions are promptly addressed and corrected.
• Your leadership needs to take an active role in oversight of your inpatient behavioral health units.

If you are in crisis or are experiencing difficult or suicidal thoughts, call the National Suicide Hotline at 1-800-273 TALK (8255).

The Door SwitchTM wants to continue the fight for more awareness and provide additional resources to dispel the myths about mental health issues and solutions for safety issues. We also continue to strive to provide a product that keeps the hospital environment safe. We continue to be committed to better practices and procedures in the mental health community. For information concerning our safety product, please click here.

Sincerely,

The Door SwitchTM

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