Patient Safety and Mental Health

1. Patient Safety and Mental Health Geoff Huggins 5 October 2010

2. Some Key Questions • What do we mean by patient safety? • What does patient safety mean for mental health? • What are the key issues and challenges? • How will we become a learning system? • What are the priorities for the next three years?

3. WHO Classification • “Patient safety incident” – event or circumstance that could or did result in unnecessary harm to the patient (narrower than the idea of ‘incident’) • “Adverse event” – an incident which results in harm to a patient (harm = physical, social or psychological) • “Close call” – an incident with the potential for harm, but prevented by intervention or chance

4. QC – Ten Rules to Redesign 5. Evidence-based decision making Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. 6. Safety as a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

5. Good Clinical Practice vs. Safe Systems • Suicide – key drivers = • Reduce access to means (anti-ligature; over the counter meds; fencing of bridges) • Better identification of depression/alcohol • Discharge planning and follow up • Effective risk assessment • Training of front line staff • Effective crisis services • Which are patient safety issues?

6. Good Clinical Practice vs. Safe Systems • Suicide – key patient safety drivers = • Reduce access to means (anti-ligature; over the counter meds; fencing of bridges) • Better identification of depression/alcohol • Discharge planning and follow up • Effective risk assessment • Training of front line staff? • Effective crisis services? • Drivers = a subset of the relevant factors

7. To Err is Human – 3 Part Strategy • Designing systems to prevent errors • Designing jobs for safety • Avoiding reliance on memory and vigilance • Simplifying and standardising key processes • Designing systems to make errors visible when they do occur – pharmacy systems • Designing procedures that can mitigate the harm to patients for errors that are not detected or intercepted – antidotes, etc.

8. Key Risk Issues in Mental Health • Harm to self • Harm to others • Medication issues • Greater bias towards managing risky behaviours by patients than on controlling the clinical environment = different approaches

9. Some Key Processes • Systems for assessing and managing risk, over time and across clinical teams • Discharge planning • CPA for those who pose a risk to others • Risk management for those who might harm themselves • Medication management • Supervision and clinical governance (Quality issue or safety issue?)

10. Crossing the Quality Chasm • “The prevention, detection, and mitigation of harm occur in learning environments, not in environments of blame and reprisal. Designing systems for safety requires specific, clear and consistent efforts to develop a work culture that encourages reporting of errors and hazardous conditions, as well as communication among staff about safety concerns. Such learning also requires attention to effective knowledge transfer, including the systematic acquisition, dissemination, and incorporation of ideas, methods and evidence that may have been developed elsewhere.”

11. A Learning System • Using the existing evidence base • Continuing the work on culture • Learning from experience: • Key issue = Critical Incident Reviews • Improve quality and consistency • System for identifying common issues • Processes for sharing knowledge to inform practice • Working with the mental health trigger tool

12. Challenge • Consensus on what we are talking about – resolve clinical vs. safety issues • Develop a focus for the work – what are the key issues • Thinking strategically – what changes will work across the system • Learning – what can we steal, what is different for mental health?