Reviewing serious incidents

The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis

AIMS AND METHOD

Serious incident management and organisational learning are international patient safety priorities. Little is known about the quality of suicide investigations and, in turn, the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time.

RESULTS

Recent literature proposes a safety-II approach in response to the limitations of RCA. The importance of applying these approaches within a mental healthcare system that advocates a zero suicide framework, grounded in a restorative just culture, is highlighted.

CLINICAL IMPLICATIONS

Although integrative reviews and syntheses have clear methodological limitations, this approach facilitates the management of a disparate body of work to advance a critical understanding of patient safety in adult community mental healthcare.

Secondary uses of patient information

The pace of development and implementation of good information management systems has been disappointingly slow and the potential benefits of using patient information for secondary purposes have not been fully realised. The secondary use of patient data might be at the level of individual practitioners or teams, or at a local-service, regional or national level. Using patient data for purposes other than direct patient care requires an understanding of the principles of case-mix, standards for recording data, the limits of accuracy of data collected in routine practice and of the principles of data security and confidentiality. The alternatives to secondary use of information are to manage the mental health service without information about the people who use it or to gather this information through channels that run in parallel to the process of clinical care.