Incident Reporting and Management Practices at Five NYS Psychiatric Centers
Given that a fundamental obligation of psychiatric hospitals is to protect patient well-being, maintaining an effective incident management system which identifies, investigates, and remedies harmful situations is vital and essential. The maintenance of such systems is mandated by the New York State Mental Hygiene Law and Office of Mental Health regulations. The State Office of Mental Health (OMH) developed an automated Incident Management and Reporting System (IMRS) to assist facilities in this area.
The Commission's review of incident management practices at five state psychiatric centers (Bronx, Creedmoor, Kirby Forensic, Manhattan, and South Beach Psychiatric Centers), surfaced several decidedly positive findings: episodes of patient elopements were reduced by more than 80% from 1994 to 1996. When incidents jeopardizing patient safety are identified, patients are provided prompt protective measures and/or treatment services; and incident investigations usually were timely and thorough, though some facilities need to improve in these areas and in the use and composition of Incident Review Committees (IRCS).
However, a major finding which needs to be addressed by OMH is the under-reporting of incidents, particularly patient-to-patient altercations, and the comparatively inconsistent interpretations of OMH regulations among various facilities. The Commission found that for every 10 events reported as incidents, another 4.6 events which appeared to warrant reporting were not, including patient fights, allegations of physical or verbal abuse, self-abuse, possession of contraband, and medication errors (Commission on Quality of Care for the Mentally Disabled).
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