NUBE 2025

A patient dying by suicide is one of the most difficult aspects of providing mental health care. Many providers struggle with coping in the aftermath of a patient death by suicide. Despite providers’ difficulty in accurately predicting who will go on to attempt or die by suicide, there is increasing pressure from regulatory bodies for healthcare organizations and providers to prevent suicide, with much scrutiny when a patient dies by suicide as well as emphasis on zero suicide. The Joint Commission (TJC) changed their definition of a sentinel event pertaining to suicide to one that occurred within seven days after last contact with levels of care, including the emergency room. As the timeframe of patient death by suicide has been expanded from three to seven days post-discharge, with broadening of the levels of care included in TJC’s revised sentinel event policy, it is anticipated that there will be increased reporting to TJC and investigations within healthcare organizations to evaluate contributory factors and root causes associated with these patient deaths. Providers who are struggling with coping in the aftermath of a patient death or other adverse outcome may have difficulty effectively contributing to a patient safety investigation such as a root cause analysis (RCA) following the death of a patient. There are existing data showing that when providers impacted by an adverse outcome are appropriately supported, they can meaningfully contribute to improving the culture of safety in an organization.

This presentation will review the intended goals of patient safety investigations such as RCAs and the unintended impact these investigations can have on providers who worked directly with patients. Participants will learn about expected acute stress reactions and strategies for coping. The session will also review ways to support providers impacted by these events, both individually and through support programs.

Learning Objectives:

Describe the intended purpose of a root cause analysis (RCA).

List three acute stress reactions and three strategies for coping after an adverse event.

Identify resources for providers impacted by adverse events.

With rising incidents related to workplace violence, Emergency Department leaders at UCHealth in Fort Collins, CO found ourselves at a loss for how to best to support our staff in continuing to provide excellent care while facing increasing concerns of violent and disruptive behaviors within the workplace. After taking steps to address workflows within the department, we knew that we needed to get creative and look outside of the walls of the hospital to address the gap seen within our community. Partnering with local law enforcement and our cities municipal court system, we have developed the Healthcare Accountability Restorative Program (HARP) which aims to address common violations within the healthcare setting to hold individuals accountable while providing opportunities for treatment. By using a restorative justice model, HARP focuses on showing the impact the incident of violence has on the victim, community and the individual with opportunities to give back to each subsect with a variety of healthcare related tasks.

In this presentation we address what workplace violence is within healthcare, impacts these disruptions have on healthcare systems nation-wide, our experience with why violent and destructive acts are not being reported, and what we have created to address these gaps within our own community. We will discuss the development process of HARP along with the implementation of the program in April 2024. We will review our initial findings including barriers, opportunities for future growth, and the successes we have discovered along the way.

Learning Objectives:

Define workplace violence in the healthcare setting.

Identify common violations within the healthcare setting that would qualify for municipal court restorative justice programming.

Learn about the Healthcare Accountability Restorative Program (HARP) implemented in Fort Collins, Colorado and understand barriers and results from the first 8 months of programming post go-live in April 2024.