Data and evidence

Mental Health Patient Safety literature

The Clinical Excellence Commission has reviewed the literature on clinical governance, specifically in relation to improving patient safety. The Agency for Clinical Innovation was commissioned to undertake a rapid review of mental health patient safety.

The literature on clinical governance strongly supports a move away from the current dominant paradigm of a top-down, policy-driven, compliance and risk-focused leadership to an approach that Don Berwick had advocated 30 years ago:

  • a vision and a culture that is fair, just and continually learning and improving
  • distributed leadership
  • substantial investment in improvement science
  • re-establishing engagement with clinicians
  • strengthening dialogue with and involvement of patients and families
  • organising for safety and improvement by empowering and supporting patients, clinicians and clinical teams.

The literature on mental health patient safety identified the main types of harm in the mental health system and the underlying and contributing factors to safety incidents in mental health services.

  • Unrecognised/Failure to respond to deterioration in a patient's physical or mental wellbeing
  • Suicide and self-harm
  • Aggression and violence
  • Compromised psychological safety
  • Communication errors, particularly in transitions and handovers
  • Absconding
  • Falls
  • Lack of cultural safety particularly for Aboriginal and Torres Strait Islander people
  • Seclusion and restraint
  • Medication errors and adverse drug events
  • Diagnostic errors
  • Work-related stress including PTSD
  • Effects on physical health

Safety data for learning and improvement

The Clinical Excellence Commission aims to increase understanding, use and communication of safety data in NSW mental health services, to better support learning and improvement. We will focus on the following areas:

  • gather safety intelligence on harms and incidents for suicides and self-harm, physical health, medication errors and adverse drug events and seclusion and restraint
  • facilitate sharing of safety data with NSW mental health services
  • promote, facilitate and support NSW mental health services in the use of QIDS for data integration and reporting.

  • Agency of Clinical Innovation (April 2019). Mental health patient safety: A rapid literature review. Sydney, Agency of Clinical Innovation (NSW): 1-24.
  • Berwick D. Continuous Improvement as an Ideal in Health Care. NEJM. 1989;320(1).
  • Braithwaite J. Changing how we think about healthcare improvement. BMJ Online. 2018:1-5. Epub 17 May 2018.
  • Dignam, P. (2009). "Accountability or responsibility? The challenge of policies in clinical psychiatry." Australasian Psychiatry 17(2): 79-81.
  • Dixon-Woods M. Improving quality and safety in health care. Clinical Medicine. 2019;19(1):47-56.
  • Gandhi T K Berwick D M Shojania K G (2016). "Patient Safety at the Crossroads." JAMA 315(17): 1829-1830.
  • Ghaferi A et al (2016). "The Next Wave of Hospital Innovation to Make Patients Safer." Harvard Business Review August 8: 1-8.
  • Ham C (2014). Transforming the NHS from within: beyond hierarchy, inspection and markets. London, The King's Fund: 1-69.
  • Ross S Naylor C. Quality Improvement in Mental Health. London: The King's Fund, 2017.
  • Short B Marr C Wright M. A new paradigm for mental-health quality and safety: are we ready? Australasian Psychiatry Online. 2019;27(1):44-9.
  • Wright M. Review of seclusion, restraint and observation of consumers with a mental illness in NSW Health facilities. Sydney: NSW Ministry of Health, 2017.