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What’s New in the Patient Safety World

March 2020

Risk Factor for Preventable Harm: Psychiatric Diagnosis



We’ve done many columns on patient safety issues related to behavioral health (see list at the end of today’s column). But virtually all our columns have focused on patients in the hospital setting. We have largely neglected patient safety risks for this population in the outpatient setting.


A case-control study in Sweden recently reported on patient-related factors associated with risk of preventable harm in first-line health care in 2 settings – primary care and the emergency department (Fernholm 2020).  The researchers found that all psychiatric diagnoses, regardless of severity, nearly doubled the risk of being a reported case of preventable harm (odds ratio 1.96). Excess risk in this group persisted even after adjustment for income and education.


The preventable harm was mostly somatic harm as oppose to psychiatric harm/suicide, and primarily involved diagnostic errors of somatic disease (46% of all preventable harm in this category was due to diagnostic errors). Smaller categories were harm from falls, surgical complications, medication-related and cross infections.


The most common psychiatric diagnoses were depression and anxiety and alcohol- or drug-related psychiatric disorders, with less frequent diagnoses being dementia, bipolar

disease, and psychotic disorders.


Differences in income and education did have some impact on the risk of preventable harm. But even after adjustment for these, the risk of preventable harm for those with psychiatric diagnoses remained significant (odds ratio 1.69).


The authors cite several prior large studies which showed that people with mental illness die prematurely and have higher rates of comorbidities than the general population. They speculate some of this may be due to “diagnostic overshadowing”, where physical symptoms are misattributed to mental illness. They note that patients with mental illness can present physical symptoms as behavioral changes, but they can also present mental discomfort as physical symptoms.


They also note that earlier studies found patients with a history of psychiatric disease have a significantly higher rate of early death after ED discharge than do patients in the

ED without such a history and that most such patients die of non-psychiatric causes


They note contributory factors identified in the hospital setting include difficulties of communication, different expressions of symptoms, problems in knowledge and information gathering, and substance misuse. But they note that reasons for increased risk in primary care have not explored.


Another recent study (Isbell 2020) looked at emotional responses of ED physicians and nurses to 3 types of encounters: one that elicited anger/frustration/irritation (angry encounter), one that elicited happiness/satisfaction/appreciation (positive encounter), and one with a patient with a mental health condition (mental health encounter). Emotions reported in angry and mental health encounters were remarkably similar, highly negative, and associated with reports of low provider engagement compared with positive encounters. The healthcare workers reported their emotions influenced their clinical decision-making and behavior most frequently in angry encounters, followed by mental health and then positive encounters. Emotions in angry and mental health encounters were associated with increased perceptions of patient safety risks; emotions in positive encounters were associated with perceptions of higher quality care.


We’ll speculate that the time factor may well play a role. In our experience, patients with those psychiatric diagnoses generally take more time during visits. So, in settings where busy schedules limit the amount of time spent with each patient (such as primary care and the emergency department), we might expect more errors to occur.


While the exact reasons for this excess risk in this population are unclear, this study should serve as a warning for first line healthcare professionals to use caution in addressing medical issues with such patients and be careful to avoid biases, particular with regard to diagnostic issues.



Some of our past columns on issues related to behavioral health:







Fernholm R, Holzmann MJ, Wachtler C, et al. Patient-related factors associated with an increased risk of being a reported case of preventable harm in first-line health care: a case-control study. BMC Family Practice 2020; 21: 20



Isbell LM, Tager J, Beals K, et al Emotionally evocative patients in the emergency department: a mixed methods investigation of providers’ reported emotions and implications for patient safety. BMJ Quality & Safety 2020; Published Online First: 27 January 2020





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