Health Alliance report of serious incidents shows drop last year, self-harm included

083016i CHA reports CambridgeFive patients of the Cambridge Health Alliance killed or seriously hurt themselves last year, a marked improvement from the total of nine suicide or serious self-harm incidents in 2014. But almost all the reduction came at Cambridge Hospital; cases at the Alliance’s Everett campus, Whidden Memorial Hospital, dropped only slightly, to three from four.

The five patients who killed or seriously injured themselves accounted for about one-sixth, or 16 percent, of the 31 total suicide/self-harm incidents last year reported by Massachusetts hospitals to the state Department of Public Health. The Alliance is a major provider of psychiatric care in the region and state, though the state report didn’t say whether patients who killed or harmed themselves were getting psychiatric care.

The Alliance has 22 psychiatric beds for adults and 22 beds for patients over 55 at Whidden; psychiatric services at Cambridge Hospital include 18 beds for adults, 14 for adolescents and 13 for children.

The figures on suicides or self-harm incidents come from the state’s annual report of “serious reportable events” at hospitals. The report covers 29 types of errors considered preventable, including suicide and self-harm. Besides that category, the Alliance also reported that patients died or were seriously hurt from medication errors, falls and burns. There was one assault of a staff member or patient, one case of a newborn being injured, three patients with severe bedsores and two surgical mistakes. The total was was 24 last year and 25 in 2014.

Alliance spokesman David Cecere said that systemwide, “we did not experience any major increase in serious reportable events in 2015 compared to previous years.”

083016i CHA reports Whidden“We have a strong, non-punitive reporting process that supports our patient safety efforts and compliance with regulatory requirements, and we encourage staff reporting and participation in improvement initiatives. Promoting a culture of safety for our patients, visitors and staff is the foundation of our system’s culture,” Cecere said.

The most intriguing error last year involved a Whidden Memorial Hospital patient who was seriously hurt after wandering away. Only one other Massachusetts hospital – CHA’s clinical partner, Beth Israel Deaconess Medical Center – reported a similar incident.

“We can’t comment on specific cases,” Cecere said, but added: “All proper steps were followed related to a patient who left the unit without notification to staff and unfortunately sustained an injury during her absence.”

For 2013, the Alliance reported more suicide/self-harm cases than any other hospital or health care system in the state: seven. That number rose to nine cases in 2014 and dropped to five last year, with the Alliance no longer topping the list.

Cambridge Hospital no longer reports the majority of suicide/self-harm incidents cases; the pattern has shifted to Whidden Memorial Hospital, which houses the Alliance’s only geriatric psychiatric unit and treats younger adult psychiatric patients. (Somerville Hospital has essentially no inpatient services, and no reported incidents.)

Whidden also reported more deaths or serious injuries from falls than did Cambridge, in both 2014 and last year.

The other acute care hospital in Cambridge, Mount Auburn Hospital, reported only 16 falls and two serious bedsores as serious events last year. But medical safety experts caution against comparing reports from different hospitals because they may have different standards and reporting practices.

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