Review of Reported Adverse Events Occurring Among the Homeless Veteran Population in the Veterans Health Administration
| Autor: | Peter D. Mills, William Gunnar, Christina Soncrant, Robin P Pendley Louis |
|---|---|
| Rok vydání: | 2021 |
| Předmět: |
education.field_of_study
medicine.medical_specialty Suicide attempt Leadership and Management business.industry Population Public Health Environmental and Occupational Health MEDLINE Opioid overdose medicine.disease Mental health humanities Patient safety Family medicine medicine education Adverse effect business Veterans Affairs |
| Zdroj: | Journal of Patient Safety. 17:e821-e828 |
| ISSN: | 1549-8425 1549-8417 |
| DOI: | 10.1097/pts.0000000000000884 |
| Popis: | Background United States veterans face an even greater risk of homelessness and associated medical conditions, mental health conditions, and fatal and nonfatal overdose as compared with nonveterans. Beginning 2009, the Department of Veterans Affairs developed a strategy and allocated considerable resources to address veteran homelessness and the medical conditions commonly associated with this condition. Objective This study aimed to examine the Veterans Health Administration National Center for Patient Safety database for patient safety events in the homeless veteran population to mitigate future risk and inform policy. Methods This was a retrospective, descriptive quality improvement study of reported patient safety events of homeless veterans enrolled in Veterans Health Administration care between January 2012 and August 2020. A validated codebook was used to capture individual patient characteristics, location and type of event, homeless status, and root causes of the events and proposed actions for prevention. Results Suicide attempt or death, elopement, delay in care, and unintentional opioid overdose were the most common adverse events reported for this population. Root causes include issues with policies, procedures, and care processes for managing and evaluating homeless patients for the risk of suicidal or overdose behaviors and discharge, poor interdisciplinary communication, and coordination of patient care. Actions included standardization of procedures for discharge, overdose and suicide risk, staff education, and purchasing new equipment. Conclusions Suicide and opioid overdose are the most serious reported health care-related adverse events in the unsheltered homeless veteran population. Failures to recognize homelessness status, communicate status, and coordinate available services are root causes of these events. |
| Databáze: | OpenAIRE |
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