Patient safety incidents within adult community-based mental health services in England: A mixed-methods examination of reported incidents, contributory factors, and proposed solutions

Phoebe Averill; Nick Sevdalis; Claire Henderson

doi:10.1017/S0033291724003532

Patient safety incidents within adult community-based mental health services in England: A mixed-methods examination of reported incidents, contributory factors, and proposed solutions

Phoebe Averill^*, Nick Sevdalis, Claire Henderson

^*Corresponding author for this work

Health Service & Population Research

Research output: Contribution to journal › Article › peer-review

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Abstract

Background

Relatively little is known about mental healthcare-related harm, with patient safety incidents (PSIs) in community-based services particularly poorly understood. We aimed to characterize PSIs, contributory factors, and reporter-identified solutions within community-based mental health services for working-age adults.

Methods

We obtained data on PSIs reported within English services from the National Reporting and Learning System. Of retrieved reports, we sampled all incidents reportedly involving ‘Death’, ‘Severe harm’, or ‘Moderate harm’, and random samples of a proportion of ‘Low harm’ or ‘No harm’ incidents. PSIs and contributory factors were classified through qualitative content analysis using existing frameworks. Frequencies and proportions of incident types were computed, and reporter-identified solutions were inductively categorized.

Results

Of 1825 sampled reports, 1443 were eligible and classified into nine categories. Harmful outcomes, wherein service influence was unclear, were widely observed, with self-harm the modal concern amongst ‘No harm’ (15.0%), ‘Low harm’ (62.8%), and ‘Moderate harm’ (37.6%) categories. Attempted suicides (51.7%) and suicides (52.1%) were the most frequently reported events under ‘Severe harm’ or ‘Death’ outcomes, respectively. Incidents common to most healthcare settings were identified (e.g. medication errors), alongside specialty-specific incidents (e.g. Mental Health Act administration errors). Contributory factors were wide-ranging, with situational failures (e.g. team function failures) and local working conditions (e.g. unmanageable workload) widely reported. Solution categories included service user-directed actions and policy introduction or reinforcement.

Conclusions

Study findings provide novel insights into incidents, contributory factors, and reported solutions within community-based mental healthcare. Targets for safety improvement are outlined, aimed at strengthening system-based prevention of incidents.

Original language	English
Article number	e8
Journal	Psychological Medicine
Volume	55
Early online date	4 Feb 2025
DOIs	https://doi.org/10.1017/S0033291724003532
Publication status	E-pub ahead of print - 4 Feb 2025

Keywords

antipsychotics
community mental health services
outpatient psychiatry
patient safety
suicide

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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Patient safety incidents within_AVERILL_Publishedonline4February2025_GOLD_VoR (CC BY-NC-ND)Final published version, 384 KBLicence: CC BY-NC-ND

Cite this

@article{8409fe819f31407da21abd061e40c58e,

title = "Patient safety incidents within adult community-based mental health services in England: A mixed-methods examination of reported incidents, contributory factors, and proposed solutions",

abstract = "BackgroundRelatively little is known about mental healthcare-related harm, with patient safety incidents (PSIs) in community-based services particularly poorly understood. We aimed to characterize PSIs, contributory factors, and reporter-identified solutions within community-based mental health services for working-age adults.MethodsWe obtained data on PSIs reported within English services from the National Reporting and Learning System. Of retrieved reports, we sampled all incidents reportedly involving {\textquoteleft}Death{\textquoteright}, {\textquoteleft}Severe harm{\textquoteright}, or {\textquoteleft}Moderate harm{\textquoteright}, and random samples of a proportion of {\textquoteleft}Low harm{\textquoteright} or {\textquoteleft}No harm{\textquoteright} incidents. PSIs and contributory factors were classified through qualitative content analysis using existing frameworks. Frequencies and proportions of incident types were computed, and reporter-identified solutions were inductively categorized.ResultsOf 1825 sampled reports, 1443 were eligible and classified into nine categories. Harmful outcomes, wherein service influence was unclear, were widely observed, with self-harm the modal concern amongst {\textquoteleft}No harm{\textquoteright} (15.0%), {\textquoteleft}Low harm{\textquoteright} (62.8%), and {\textquoteleft}Moderate harm{\textquoteright} (37.6%) categories. Attempted suicides (51.7%) and suicides (52.1%) were the most frequently reported events under {\textquoteleft}Severe harm{\textquoteright} or {\textquoteleft}Death{\textquoteright} outcomes, respectively. Incidents common to most healthcare settings were identified (e.g. medication errors), alongside specialty-specific incidents (e.g. Mental Health Act administration errors). Contributory factors were wide-ranging, with situational failures (e.g. team function failures) and local working conditions (e.g. unmanageable workload) widely reported. Solution categories included service user-directed actions and policy introduction or reinforcement.ConclusionsStudy findings provide novel insights into incidents, contributory factors, and reported solutions within community-based mental healthcare. Targets for safety improvement are outlined, aimed at strengthening system-based prevention of incidents.",

keywords = "antipsychotics, community mental health services, outpatient psychiatry, patient safety, suicide",

author = "Phoebe Averill and Nick Sevdalis and Claire Henderson",

note = "Publisher Copyright: {\textcopyright} The Author(s), 2025. Published by Cambridge University Press.",

year = "2025",

month = feb,

day = "4",

doi = "10.1017/S0033291724003532",

language = "English",

volume = "55",

journal = "Psychological Medicine",

issn = "0033-2917",

publisher = "Cambridge University Press",

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TY - JOUR

T1 - Patient safety incidents within adult community-based mental health services in England

T2 - A mixed-methods examination of reported incidents, contributory factors, and proposed solutions

AU - Averill, Phoebe

AU - Sevdalis, Nick

AU - Henderson, Claire

PY - 2025/2/4

Y1 - 2025/2/4

N2 - BackgroundRelatively little is known about mental healthcare-related harm, with patient safety incidents (PSIs) in community-based services particularly poorly understood. We aimed to characterize PSIs, contributory factors, and reporter-identified solutions within community-based mental health services for working-age adults.MethodsWe obtained data on PSIs reported within English services from the National Reporting and Learning System. Of retrieved reports, we sampled all incidents reportedly involving ‘Death’, ‘Severe harm’, or ‘Moderate harm’, and random samples of a proportion of ‘Low harm’ or ‘No harm’ incidents. PSIs and contributory factors were classified through qualitative content analysis using existing frameworks. Frequencies and proportions of incident types were computed, and reporter-identified solutions were inductively categorized.ResultsOf 1825 sampled reports, 1443 were eligible and classified into nine categories. Harmful outcomes, wherein service influence was unclear, were widely observed, with self-harm the modal concern amongst ‘No harm’ (15.0%), ‘Low harm’ (62.8%), and ‘Moderate harm’ (37.6%) categories. Attempted suicides (51.7%) and suicides (52.1%) were the most frequently reported events under ‘Severe harm’ or ‘Death’ outcomes, respectively. Incidents common to most healthcare settings were identified (e.g. medication errors), alongside specialty-specific incidents (e.g. Mental Health Act administration errors). Contributory factors were wide-ranging, with situational failures (e.g. team function failures) and local working conditions (e.g. unmanageable workload) widely reported. Solution categories included service user-directed actions and policy introduction or reinforcement.ConclusionsStudy findings provide novel insights into incidents, contributory factors, and reported solutions within community-based mental healthcare. Targets for safety improvement are outlined, aimed at strengthening system-based prevention of incidents.

AB - BackgroundRelatively little is known about mental healthcare-related harm, with patient safety incidents (PSIs) in community-based services particularly poorly understood. We aimed to characterize PSIs, contributory factors, and reporter-identified solutions within community-based mental health services for working-age adults.MethodsWe obtained data on PSIs reported within English services from the National Reporting and Learning System. Of retrieved reports, we sampled all incidents reportedly involving ‘Death’, ‘Severe harm’, or ‘Moderate harm’, and random samples of a proportion of ‘Low harm’ or ‘No harm’ incidents. PSIs and contributory factors were classified through qualitative content analysis using existing frameworks. Frequencies and proportions of incident types were computed, and reporter-identified solutions were inductively categorized.ResultsOf 1825 sampled reports, 1443 were eligible and classified into nine categories. Harmful outcomes, wherein service influence was unclear, were widely observed, with self-harm the modal concern amongst ‘No harm’ (15.0%), ‘Low harm’ (62.8%), and ‘Moderate harm’ (37.6%) categories. Attempted suicides (51.7%) and suicides (52.1%) were the most frequently reported events under ‘Severe harm’ or ‘Death’ outcomes, respectively. Incidents common to most healthcare settings were identified (e.g. medication errors), alongside specialty-specific incidents (e.g. Mental Health Act administration errors). Contributory factors were wide-ranging, with situational failures (e.g. team function failures) and local working conditions (e.g. unmanageable workload) widely reported. Solution categories included service user-directed actions and policy introduction or reinforcement.ConclusionsStudy findings provide novel insights into incidents, contributory factors, and reported solutions within community-based mental healthcare. Targets for safety improvement are outlined, aimed at strengthening system-based prevention of incidents.

KW - antipsychotics

KW - community mental health services

KW - outpatient psychiatry

KW - patient safety

KW - suicide

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U2 - 10.1017/S0033291724003532

DO - 10.1017/S0033291724003532

M3 - Article

C2 - 39901859

AN - SCOPUS:85217545461

SN - 0033-2917

VL - 55

JO - Psychological Medicine

JF - Psychological Medicine

M1 - e8

ER -

Patient safety incidents within adult community-based mental health services in England: A mixed-methods examination of reported incidents, contributory factors, and proposed solutions

Abstract

Keywords

UN SDGs

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