Volume 17, Issue 1 (9-2026)
3 2026, 17(1): 60-67 |
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Rajaei A, Moradi A, Esmailpour H, Mahmoudi E, Sanagoo A. Report of Two Cases of Drug Overdose Suicide Attempts in Depressed Patients Hospitalized in a Psychiatric Ward: Patient Safety Challenges and Lessons Learned. 3 2026; 17 (1) :60-67
URL: http://ndhj.lums.ac.ir/article-1-496-en.html
URL: http://ndhj.lums.ac.ir/article-1-496-en.html
Abstract: (12 Views)
Background and Objectives: Patients with major depressive disorder admitted to psychiatric wards, particularly those with a history of suicide attempts and substance abuse, are at high risk of self-harm behaviors. Despite the implementation of standard suicide prevention protocols, patients’ unauthorized access to psychotropic medications and unsupervised medication use, remain important patient safety challenges in psychiatric settings. This report presents two cases of suicide attempts involving medication overdose and discusses lessons learned to improve patient safety.
Case Report: Two female patients, aged 37 and 29 years, with major depressive disorder, a history of suicide attempts, and substance abuse, were admitted to a psychiatric ward. Both patients received combination pharmacotherapy, and medical orders included close monitoring, control of sharp objects, and prevention of unsupervised medication use.
However, on the 14th day of hospitalization for the first patient and the 11th day for the second, both patients attempted suicide by ingesting five 1-mg clonazepam tablets and five 0.5-mg alprazolam tablets that had been brought into the ward without authorization.
Both patients informed the nurse within a few minutes of ingestion. Immediate interventions included notifying the attending physician, gastric lavage via a nasogastric tube, intravenous fluid therapy, continuous monitoring of vital signs, and consultation with the Poison Control Center. Following prompt therapeutic interventions, the general condition of both patients stabilized, and they were transferred to the next shift in full consciousness.
Conclusion: These cases demonstrate that written monitoring orders alone are insufficient to prevent high-risk patients from accessing medications. Strengthening nursing supervision, implementing strict control over medication entry and distribution, conducting periodic inspections of patients’ personal belongings, using standardized patient safety checklists, and creating a safer therapeutic environment may help reduce the risk of recurrence of similar events.
Case Report: Two female patients, aged 37 and 29 years, with major depressive disorder, a history of suicide attempts, and substance abuse, were admitted to a psychiatric ward. Both patients received combination pharmacotherapy, and medical orders included close monitoring, control of sharp objects, and prevention of unsupervised medication use.
However, on the 14th day of hospitalization for the first patient and the 11th day for the second, both patients attempted suicide by ingesting five 1-mg clonazepam tablets and five 0.5-mg alprazolam tablets that had been brought into the ward without authorization.
Both patients informed the nurse within a few minutes of ingestion. Immediate interventions included notifying the attending physician, gastric lavage via a nasogastric tube, intravenous fluid therapy, continuous monitoring of vital signs, and consultation with the Poison Control Center. Following prompt therapeutic interventions, the general condition of both patients stabilized, and they were transferred to the next shift in full consciousness.
Conclusion: These cases demonstrate that written monitoring orders alone are insufficient to prevent high-risk patients from accessing medications. Strengthening nursing supervision, implementing strict control over medication entry and distribution, conducting periodic inspections of patients’ personal belongings, using standardized patient safety checklists, and creating a safer therapeutic environment may help reduce the risk of recurrence of similar events.
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