Conceptual and practical challenges associated with understanding patient safety within community-based mental health services

INTRODUCTION

Patient safety problems stemming from healthcare delivery constitute a global public health concern and represent a pervasive barrier to improving care quality and clinical outcomes. However, evidence generation into safety in mental health care, particularly regarding community-based mental health services, has long fallen behind that of physical health care, forming the focus of fewer research publications and developed largely in isolation from the wider improvement science discipline. We aimed to investigate the state of the field, along with key conceptual and empirical challenges to understanding patient safety in community-based mental health care.

METHODS

A narrative review surveyed the literature to appraise the conceptual obstacles to advancing the science of patient safety in community-based mental health services. Sources were identified through a combination of a systematic search strategy and targeted searches of theoretical and empirical evidence from the fields of mental health care, patient safety and improvement science.

RESULTS

Amongst available evidence, challenges in defining safety in the context of community mental health care, evaluating safety in long-term care journeys and establishing what constitutes a 'preventable' safety problem, were identified. A dominant risk management approach to safety in mental health care, positioning service users as the origin of risk, has seemingly prevented a focus on proactive safety promotion, considering iatrogenic harm and latent system hazards.

CONCLUSION

We propose a wider conceptualization of safety and discuss the next steps for the integration and mobilization of disparate sources of 'safety intelligence', to advance how safety is conceived and addressed within community mental health care.

PATIENT AND PUBLIC CONTRIBUTION

This paper was part of a larger research project aimed at understanding and improving patient safety in community-based mental health care. Although service users, carers and healthcare professionals were not involved as part of this narrative review, the views of these stakeholder groups were central to shaping the wider research project. For a qualitative interview and focus group study conducted alongside this review, interview topic guides were informed by this narrative analysis, designed jointly and piloted with a consultation group of service users and carers with experience of community-based mental health services for working-age adults, who advised on key questioning priorities.

Nurses' Views Highlight a Need for the Systematic Development of Patient Safety Culture in Forensic Psychiatry Nursing

BACKGROUND

Although forensic nurses work with the most challenging psychiatric patients and manifest a safety culture in their interactions with patients, there have been few studies on patient safety culture in forensic psychiatric nursing.

OBJECTIVES

The aim of this qualitative study was to describe nurses' views of patient safety culture in their working unit and daily hospital work in 2 forensic hospitals in Finland.

METHODS

Data were collected over a period of 1 month by inviting nurses to answer an open-ended question in an anonymous Web-based questionnaire. A qualitative inductive analysis was performed on nurses' (n = 72) written descriptions of patient safety culture in state-owned forensic hospitals where most Finnish forensic patients are treated.

RESULTS

Six main themes were identified: "systematization of an open and trusting communication culture," "visible and close interaction between managers and staff," "nonpunitive responses to errors, learning and developing," "balancing staff and patient perspectives on safety culture," "operational safety guidelines," and "adequate human resources to ensure safety."

CONCLUSIONS

The findings highlight the influence of the prevailing culture on safety behaviors and outcomes for both healthcare workers and patients. Additionally, they underline the importance of an open culture with open communication and protocols.