Between the checks: The limits of manual observation in inpatient psychiatric safety
Welcome to the first of a series of posts exploring the unique realities of inpatient psychiatric care—one of the most clinically demanding and critical environments in healthcare today.
As CEO of LIO, I’ve spent the last 25 years in healthcare technology, with the past 2+ years deeply embedded in behavioral health. Having visited dozens of acute mental health hospitals in both the UK and the US, I see how different and misunderstood behavioral health is compared to "regular" care (yes, the air quotes are purposeful, given some of the stigma attached to mental health). I believe it is important to shine a light on an area of healthcare that must be fixed. These posts are meant to show hope and to highlight concern for an overlooked system that is meant to serve the most vulnerable.
The bar accreditors set
First, as outlined by the Joint Commission, high-risk patients in units with ligature or other safety risks must be under continuous observation or with the ability to intervene immediately. When it isn't continuous, it is close: Q5s, Q15s, Q30s, and so on. The Q stands for quaque, Latin for "every," and the number represents minutes (how often the patient must be checked).
These checks, the Qs, along with constant and special observation (1:1s, within-eyesight watches, intermittent rounds) are the backbone of inpatient safety. In fact, up to one in five psychiatric admissions receives some form of special observation during their stay.
Second, units must actively manage ligature risk. That means ongoing ligature risk assessment and ligature-resistant environments. Unfortunately, inpatient suicide remains one of the most reported sentinel events, and hanging or ligature is the leading method.
Why manual observation falls short
Despite the dedication of clinical teams, constant manual observation presents a challenge for four primary reasons:
- Human limits: Attention naturally decays over a long, stressful shift. Sadly, even a brief involuntary lapse in focus can be enough for a determined patient.
- Architectural blind spots: Even the best-designed hospitals have line-of-sight blind spots, and the interval between intermittent checks is, by definition, unobserved. Even generously assuming each check takes a full minute, a patient on Q15s is directly observed under 7% of the day. The rest is unwatched.
- Thin evidence it works: Constant manual observation carries a significant economic burden without a consistently demonstrated reduction in adverse events.
- Administrative burden: Time spent on manual observation is time taken away from direct clinical interaction, often leading to increased agency spend, overtime, and staff burnout.
Taken together, while manual observation strives to be a safety practice, it is problematic at best. It is also one of the largest controllable cost lines on the unit, which is the subject of my next post.
There is a better way
We partner with facilities to significantly reduce risk and improve safety through a technology-enabled, layered model: trained staff making the clinical calls, with continuous technology closing the gaps that human observation cannot.
At LIO, we turn mental health facilities into ambient sensing environments: continuous, privacy-preserving, contactless patient monitoring of vital signs, presence, and activity that runs between the checks, surfaces risk earlier, and supports clinical judgment rather than replacing it. Unlike a virtual sitter that simply moves the watching to a screen, ambient sensing works continuously and complements virtual nursing models by giving bedside and remote staff a live data layer. Independent studies of continuous monitoring programs show large drops in 1:1 sitter hours and cost, with no increase in falls or self-harm.
To be clear, we are not arguing against observation. We are arguing to close the gaps that staff cannot cover alone. Technology like ours lets staff focus on clinical care while reducing administrative burdens and helping facilities respond to risk events the moment they happen, ultimately preventing self-harm and saving lives.
That is why I am proud to lead this business, and why I am excited to tell you more in my next post: PLGL: Naming the biggest controllable line in the inpatient psychiatry P&L.
If you work in behavioral health and this resonates, follow along for the next post, or reach out. We would value the conversation.
Author: Todd Haedrich, CEO, LIO
