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Donovan AL, Aaronson EL, Black L, et al. Jt Comm J Qual Patient Saf. 2021;47:23-30.
Patient suicide, attempted suicide, or self-harm are considered ‘never events.’ This article describes the development and implementation of a safety protocol for emergency department (ED) patients at risk for self-harm, including the creation of safe bathrooms and increasing the number of trained observers in the ED. Implementation of the protocol was correlated with lower rates of self-harm.  
Quinlivan L, Littlewood DL, Webb RT, et al. J Mental Health. 2020;29:1-5.
This editorial proposes adapting a patient safety paradigm – Safety-I or Safety-II – to provide insights into suicidal behavioral, as it is a preventable outcome and health services play an important role in reducing its incidence. The new paradigm – Safety III – would incorporate on health services research combined with ethnography and strong patient/public involvement.
Thibaut BI, Dewa LH, Ramtale SC, et al. BMJ Open. 2019;9:e030230.
This exploratory systematic review aimed to describe the state of the research on patient safety in inpatient mental health settings. Authors included 364 papers, representing 31 countries and data from over 150,000 participants. The existing research base was categorized into ten broad safety categories – interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorized leave, clinical decision making, falls, and infection prevention/control; papers were of varying quality with the majority of papers assessed as “fair”. The authors note that several areas of patient safety in inpatient mental health are particularly understudied, such as suicide, as the review only yielded one study meeting inclusion criteria.