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Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).

This systematic review examined common systems factors affecting suicide deaths in mental health care. Seven themes contributing to suicide deaths were identified: (1) inappropriate or incomplete risk assessment; (2) lack of family involvement; (3) inadequate transitions and communication between different care teams; (4) lack of adherence to policies and procedures; (5) treatment not in line with current guidelines; (6) access to means and observation and; (7) lack of specialist services within the community.

This study describes the application of Toyota Production System principles, which emphasize designing standardized and reliable work processes by an iterative process of testing and evaluation, to improving patient safety and continuity of care at a psychiatric institution.