Psych CASC / OSCE · Public-community — quality improvement and patient safety
Ward safety crisis after post-discharge suicide — CASC/management station
MRCPsych/FRANZCP-style management station integrating just culture, PDSA measurement, Safewards, and suicide-prevention service design.
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Study tools
Target exams
FRANZCPMRCPsychABPNMD-DNB
Prompt
An acute inpatient unit had a patient die by suicide five days after discharge without documented follow-up. Seclusion hours are rising, two wrong-depot near misses occurred this month, and nurses say incident reporting feels punitive. You are the registrar asked to outline immediate response, open disclosure principles, systems analysis, a PDSA project, and evidence-linked change packages without inventing local legal section numbers.
Station tasks (approx. 7–10 minutes)
Station tasks: (1) immediate clinical and organisational response after the death; (2) open disclosure and support for family and staff (second victims); (3) systems analysis of discharge failure and near-miss depots; (4) propose a PDSA project with measures; (5) name evidence-linked packages (Safewards; suicide service recommendations; environmental ligature work).[1][3][5][6]
References10ShowHide
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- [2]Leape LL Error in medicine JAMA, 1994.PMID 7503827
- [3]Bowers L, James K, Quirk A, et al. Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial Int J Nurs Stud, 2015.PMID 26166187
- [4]While D, Bickley H, Roscoe A, et al. Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional before-and-after observational study Lancet, 2012.PMID 22305767
- [5]Appleby L, Shaw J, Amos T, et al. Suicide within 12 months of contact with mental health services: national clinical survey BMJ, 1999.PMID 10231250
- [6]Silver SA, Harel Z, McQuillan R, et al. How to Begin a Quality Improvement Project Clin J Am Soc Nephrol, 2016.PMID 27016497
- [7]Grasso BC, Rothschild JM, Genest R, Bates DW What do we know about medication errors in inpatient psychiatry? Jt Comm J Qual Saf, 2003.PMID 12953603
- [8]Hunt IM, Windfuhr K, Shaw J, et al. Ligature points and ligature types used by psychiatric inpatients who die by hanging: a national study J Affect Disord, 2012.PMID 22343063
- [9]Donabedian A Evaluating the quality of medical care Milbank Mem Fund Q, 1966.PMID 5338568
- [10]Thibaut B, Dewa LH, Ramtale SC, et al. Patient safety in inpatient mental health settings: a systematic review BMJ Open, 2019.PMID 31874869