National Association of State Mental Health Program Directors
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B. What was the result (seclusion, restraint, involuntary medication, any
injuries to staff or patients
C. Who was involved in events leading up to the seclusion, restraint or
involuntary procedure
D. What were the antecedents (patient history, past events, behavior
immediately prior to the event)
E. Was there any warning or change in behavior prior to the event and what
did staff do?
F. Did we know that this was a high risk for violence person? If so, what had
been done to prevent this event?
G. What was the source of the conflict, if any?
H. What did staff do?
I. When the escalating behavior was noted, were other interventions tried,
and if so, what and what was the response?
J. Did the person have a relationship with anyone on staff at this time of the
event and did that person try to intervene?
K. Was the person offered alternatives and what was the response?
L. Had the person developed a safety plan and was that used?
M. What staff were directly involved and are they ok?
N. Is the person safe and where are they now?
O. What have staff done to prevent another occurrence?
P. What is the person saying at this point, if anything?
Q. Were the event “observers” debriefed and how are they?
R. Were the staff involved debriefed and how are they?
S. Is there anything, right now, that you can add regarding how this event
could have been avoided?
T. Can you attend or “call in” for the formal event debriefing and, if not, how
can we get your information to the team members who will debrief this
event.
U. Is there anything that can be done now to prevent this from happening
again?
3. The Executive staff member on call is expected to take this call or call back in a
timely manner. It is recommended that this staff person “on call” make informal
notes regarding what happened along with any notes that indicate a need to
follow-up the next day. These “called-in” occurrences need to be discussed with
other senior clinical staff the next working day and all issues requiring follow-up
passed on to the appropriate person.
4. In general, this procedure is meant to provide three outcomes. First, to make the
executive team well-acquainted with what occurs on units in a timely manner as
well as to orient executive staff to the working conditions that direct care staff are
facing. Second, this procedure is done to try and make direct care staff aware that
the agency leadership is also affected by these events, is supportive, and is
available. Third, this activity is designed to make executive staff, with formal
power, aware of policy, procedures, and operational issues that could be creating