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National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021

System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergent and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.
Sharma AE, Yang J, Del Rosario JB, et al. Jt Comm J Qual Patient Saf. 2021;47:5-14.
Ambulatory care settings are receiving increased attention as a focus for patient safety improvements. Using data from a multistate patient safety organization (PSO) database, the researchers sought to characterize patterns and characteristics of patient safety incidents reported in ambulatory care settings. Analyses found that 5.9% of events resulted in severe harm and 1.9% resulted in patient death. Over half of the events were from outpatient subspecialty care; fewer events occurred in home/community (5.2%), primary care (2.1%), or dialysis (2.0%) settings. Medication-related events were most common, followed by clinical deterioration and falls. Predictors of higher harm included diagnostic errors, patient/caregiver challenges, and events occurring in home/community or psychiatric settings. These results can help ambulatory care settings target safety events and develop systems-level prevention strategies.  
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30:567-576.
This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.
Berzins K, Baker J, Louch G, et al. Health Expect. 2020;23:549-561.
This qualitative study interviewed patients and caregivers about their experiences and perceptions of safety within mental health services. These interviews identified a broad range of safety issues; the authors suggest that patient safety in mental health services could be expanded to include harm caused trying to access services and self-harm provoked by contact with, or rejection from, services.
Wyder M, Ray MK, Roennfeldt H, et al. Int J Qual Health Care. 2020;32:285-291.
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.
Salas E, Bisbey TM, Traylor AM, et al. Ann Rev Org Psychol Org Behav. 2020;7:283-313.
This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.
Haw C, Stubbs J, Dickens GL. J Psychiatr Ment Health Nurs. 2014;21:797-805.
Researchers interviewed mental health nurses to determine perceived obstacles to reporting medication administration errors or near misses. Many factors were identified, including insufficient knowledge, fear of consequences, or burden of work associated with reporting. These have also been cited as reasons for under-reporting of errors in prior nursing studies.
A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.