Patient, provider, and system factors contributing to patient safety events during medical and surgical hospitalizations for persons with serious mental illness

Emma Beth McGinty, David Thompson, Peter J. Pronovost, Lisa B. Dixon, Eliseo Guallar, Daniel E Ford, Elizabeth Khaykin Cahoon, Romsai Tony Boonyasai, Gail L Daumit

Research output: Contribution to journalArticle


This study aimed to explore patient-, provider-, and system-level factors that may contribute to elevated risk of patient safety events among persons with serious mental illness (SMI). We conducted a medical record review of medical/surgical admissions in Maryland hospitals from 1994 to 2004 for a community-based sample of adults with SMI (N = 790 hospitalizations). We estimated the prevalence of multiple patient, provider, and systemfactors that could influence patient safety among persons with SMI.We conducted a case crossover analysis to examine the relationship between these factors and adverse patient safety events. Patients' mental status, level of consciousness, disease severity, and providers' lack of patient monitoring, delay/failure to seek consultation, lack of trainee supervision, and delays in care were positively associated with adverse patient safety events (p < 0.05). Efforts to reduce SMI-related patient safety risks will need to be multifaceted and address both patient- and provider-level factors.

Original languageEnglish (US)
Pages (from-to)495-501
Number of pages7
JournalJournal of Nervous and Mental Disease
Issue number6
StatePublished - 2017



  • Hospitalization
  • Medical
  • Patient safety
  • Serious mental illness
  • Surgical

ASJC Scopus subject areas

  • Psychiatry and Mental health

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