Care Delivery within Community Mental Health Teams.

Book/Report

Care Delivery within Community Mental Health Teams.

April 5, 2023

Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.

Patient suicide is a sentinel event. This report examines a suicide incident that identified problems with risk assessment and identification, family engagement, and medication management in the context of mental health provision when supporting patients in psychological distress.

Information

Summary

Free full text (PDF)

Related Resources From the Same Author(s)

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

May 31, 2023

Access to Clinical Information at the Bedside.

March 1, 2023

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

September 6, 2023

Non-accidental Injuries in Infants Attending the Emergency Department.

May 17, 2023

Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment.

April 26, 2023

Wrong Site Surgery–Wrong Tooth Extraction.

June 9, 2021

Never Events Analysis of HSIB's National Investigations Report.

February 3, 2021

Investigation into Electronic Prescribing and Medicines Administration Systems and Safe Discharge.

November 13, 2019

Maternity Pre-arrival Instructions by 999 Call Handlers.

March 16, 2022

Weight-based Medication Errors in Children.

February 16, 2022

The Diagnosis of Ectopic Pregnancy.

April 8, 2020

Administering High-Strength Insulin from a Pen Device in Hospital.

September 14, 2022

Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

June 23, 2021

Decontamination of Surgical Instruments.

June 8, 2022

Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.

January 22, 2020

HSIB Education.

October 19, 2022

A Thematic Analysis of HSIB's First 22 Investigations.

September 29, 2021

Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.

November 4, 2020

Inadvertent Administration of an Oral Liquid Medicine into a Vein.

April 1, 2019

Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hospital.

October 28, 2020

HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work.

September 21, 2022

Risks to Medication Delivery Using Ambulatory Infusion Pumps – Design and Usability in Inpatient Settings.

February 14, 2024

Positive Patient Identification.

February 21, 2024

Listening, Learning, Responding to Concerns.

April 12, 2023

Just a Cup of Tea – an Introduction to the SEIPS Framework.

May 24, 2023

Improving Patient Safety Culture – A Practical Guide.

August 2, 2023

Healthcare Safety Investigations Conference 2022.

August 3, 2022

Workforce and Patient Safety.

April 24, 2024

State of Care.

November 20, 2023

Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports.

April 16, 2024

Broken Trust: Making Patient Safety More than Just a Promise.

July 19, 2023

Safety Management Systems - an Introduction for Healthcare.

November 29, 2023

SHOT Annual Report.

July 19, 2023

Global State of Patient Safety 2023.

December 20, 2023

Discharge from Mental Health Care: Making it Safe and Patient-centred.

April 17, 2024

Prevention of perioperative medication errors.

March 17, 2023

National Safety Standards for Invasive Procedures (NatSSIPs2).

February 7, 2023

Final Report of the Ockenden Review.

April 27, 2022

The prisoner.

March 29, 2023

A Just Culture Guide.

April 18, 2018

Mothers face broken addiction treatment system.

April 12, 2023

Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane.

March 29, 2023

Hospital ‘black boxes’ put surgical practices under the microscope.

March 29, 2023

I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients.

March 22, 2023

Feds move to rein in prior authorization, a system that harms and frustrates patients.

March 22, 2023

State of Healthcare 2008.

November 15, 2008

Why hospitals still make serious medical errors—and how they are trying to reduce them.

March 29, 2023

Few hospitals are willing to bear the cost of providing psychiatric care for kids.

March 22, 2023

Minimize medication errors in urgent care clinics.

March 15, 2023

Using A.I. to detect breast cancer that doctors miss.

March 15, 2023

Improving Safety in Maternity Services: a Toolkit for Teams.

April 25, 2012

Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.

April 2, 2014

Roadmap to Health Care Safety for Massachusetts.

May 3, 2023

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

May 4, 2022

Investigating the mediating effect of patient self-efficacy on the relationship between patient safety engagement and patient safety in healthcare professionals.

March 22, 2023

New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes.

February 15, 2023

Safer Together Survey: Advancing Patient and Workforce Safety

January 18, 2023

VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.

May 3, 2023

Improving Quality and Safety in Healthcare.

October 26, 2022

Addressing Medical Gaslighting to Improve Maternal Health—Together.

March 29, 2023

TeamSTEPPS Core Curriculum.

July 19, 2023

Medical Office Survey on Patient Safety Culture.

September 1, 2021

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

August 16, 2023

Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors.

August 2, 2023

Preventing home medication errors.

April 12, 2023

Safety in Doses.

September 16, 2009

Review of Patient Safety for Children and Young People.

July 1, 2009

Exploring the Potential Use of Safety Cases in Health Care.

March 4, 2015

Safety First: a Report for Patients, Clinicians and Healthcare Managers.

January 17, 2007

Understanding and Improving Diagnostic Safety in Ambulatory Care.

September 6, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

APSF Stoelting Conference.

September 6, 2023 - September 7, 2023

AHRQ Safety Program for MRSA Prevention.

February 14, 2023

Naming the "baby" or the "beast"? The importance of concepts and labels in healthcare safety investigation.

April 5, 2023

CHPSO Annual Reports.

August 15, 2023

Never Events--Framework 2010-11.

March 4, 2010

Patient Safety Authority Annual Reports.

May 1, 2023

Safer Clinical Systems.

May 13, 2015

Systems-Based Approaches to Improve Patient Safety by Improving Healthcare Worker Safety and Well-Being (R01 Clinical Trial Optional).

December 20, 2023

Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders.

November 1, 2023

Voices from the Frontlines of Health Care Safety.

May 31, 2023

Information Design for Patient Safety: A Guide to the Graphic Design of Medication Packaging. 2nd edition.

November 23, 2007

Network of Patient Safety Databases Chartbook.

November 8, 2023

NPSD Data Spotlight: Patterns of Fall Interventions.

November 15, 2023

Dissemination and Implementation of Equity-Focused Evidence-Based Interventions in Healthcare Delivery Systems (R18).

March 8, 2023

Manchester Patient Safety Framework (MaPSaF).

March 8, 2006

Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care.

October 27, 2021

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

February 15, 2023

Medical Error.

September 28, 2005

Learning to Use Patient Stories.

December 8, 2010

Safely Home: What Happens When People Leave Hospital Care Settings?

August 26, 2015

Involving Patients in Improving Safety.

January 30, 2013

Patient Stories 2013: Time for Change.

December 11, 2013

Complaints to the Parliamentary and Health Service Ombudsman.

October 23, 2023

Systems Analysis of Critical Incidents: the London Protocol.

December 19, 2007

With Safety in Mind: Mental Health Services and Patient Safety.

September 6, 2006

Engaging Patients for Patient Safety: Advocacy Brief.

February 14, 2024

A Transformational Effort on Patient Safety.

September 13, 2023

Avoiding Unconscious Bias: a Guide for Surgeons.

August 24, 2016

National Diabetes Inpatient Audit -- Harms.

July 8, 2021

Related Resources

Patient Safety Innovations

Suicide Prevention in an Emergency Department Population: ED-SAFE

April 24, 2024

Discharge from Mental Health Care: Making it Safe and Patient-centred.

April 17, 2024

Should dignity preservation be a precondition for safety and a design priority for healing in inpatient psychiatry spaces?

April 10, 2024

WebM&M Cases

Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation

March 27, 2024

Implementing and evaluating patient-focused safety technology on adult acute mental health wards.

March 13, 2024

Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients.

February 28, 2024

Anticipating patient safety events in psychiatric care.

February 7, 2024

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

September 6, 2023

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: a prioritisation nominal group technique.

August 16, 2023

Only 1 in 5 people with opioid addiction get the medications to treat it, study finds.

August 16, 2023

Why stigma matters in addressing alcohol harm.

August 9, 2023

Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department.

July 26, 2023

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

July 5, 2023

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

July 5, 2023

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review.

June 28, 2023

WebM&M Cases

The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.

June 14, 2023

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

June 7, 2023

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

May 24, 2023

Structural racism in behavioral health presentation and management.

May 17, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Mothers face broken addiction treatment system.

April 12, 2023

WebM&M Cases

Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.

March 29, 2023

Few hospitals are willing to bear the cost of providing psychiatric care for kids.

March 22, 2023

Crisis in the Lakeshore Hospital ER.

March 8, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Access to Clinical Information at the Bedside.

March 1, 2023

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

February 15, 2023

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

December 7, 2022

Influencing a culture of quality and safety through huddles.

November 9, 2022

See More About The Topic

Psychiatric Facilities

General Public

Home Care

Health Care Executives and Administrators

Policy Makers