Improving safety and quality in mental healthcare

Student thesis: Doctoral ThesisDoctor of Philosophy


Background: Patient safety incidents are a leading cause of death and disability worldwide. Mental health services have, however, been largely absent from the evolving patient safety evidence base, in which over 20 years of publications have concentrated primarily on physical healthcare. Safety in community-based mental health services, where the majority of care is delivered, represents a particularly poorly understood and insufficiently researched area. Consequently, there is both a paucity of evidence about the principal risks to safety and a lack of conceptual clarity over what constitutes a patient safety problem in this context. Through five studies, this research programme sought to address this knowledge gap.

The overarching aims of this research were to study the nature of patient safety problems in community-based mental healthcare and to identify priority areas for future interventional research. These aims were achieved through the involvement of stakeholders and with the triangulation of findings from existing research evidence, analyses of routinely collected data about patient safety incidents, and qualitative interview and focus group data.

Study one: A narrative review investigated the current state of affairs in the field of patient safety in mental healthcare. Informed by existing literature from the disciplines of patient safety and improvement science, this review illuminated conceptual and practical issues in applying patient safety principles to community-based mental healthcare. Challenges in determining what constitutes a patient safety problem for this service user population were detailed. As the field seeks to mature, potential solutions for the advancement of the science and improvement of patient safety were explored in this care context.

Study two: A systematic scoping review mapped evidence on the nature of patient safety problems in community-based mental healthcare settings, their contributory factors, and evaluated interventions to improve safety. Seven key categories of research were identified: management of risks of harm to self; management of risks of violence and aggression; clinical assessment and decision-making; medication safety; ongoing monitoring and review; communication, handover and multiagency working; and safety of the healthcare system. Contributory factors were mapped to an existing empirical framework, the Yorkshire Contributory Factors Framework – Mental Health adaptation (YCFF-MH).

Studies three and four: Routine data about patient safety incidents, as reported by staff within mental health services, were analysed. These studies used data from the National Reporting and Learning System, a national database of patient safety incident reports from healthcare settings within England and Wales. An exploratory pilot study was first undertaken to refine an approach to data sampling, seeking also to identify potential areas for learning about safety through these underutilised data. Next, an in-depth mixed-methods study was conducted to provide detailed insights into patient safety from the perspective of reporting healthcare professionals within community-based mental health services. Using existing empirical frameworks for safety incident analysis, nine key categories of patient safety incident were identified amongst sampled data, including problems stemming from care administration; referral; diagnosis and assessment; and issues of risk management. The contributory factors to patient safety problems were assessed, according to the YCFF-MH, along with reporter appraisals of incident preventability, and proposed solutions to prevent their reoccurrence.

Study five: A final study involved semi-structured qualitative interviews and focus groups with a purposive sample of service users, carers, and healthcare providers. Stakeholder perspectives on patient safety issues were examined, with four key themes and several subthemes developed through a reflexive approach to thematic analysis. Findings elucidated the range of ways in which patient safety is conceptualised by those who use or interact with community-based mental health services. Participant narratives were indicative of priority areas for improving patient safety in this care context, as well as the means by which the mental healthcare system should be strengthened to prevent patient harm.

Conclusions: Triangulation of findings from each study allowed for comparisons between existing theory and literature, formally reported patient safety incidents, and the broader but overlapping range of issues presented by interview and focus group participants. Study findings presented several novel insights about patient safety in community-based mental healthcare, including cross-cutting themes as to the nature of patient safety problems in these services. Key topics which were observed across studies included: the management of risks; access and transitions; medication; communication; feeling safe; and the organisation of care. Implications are indicated for future efforts to improve patient safety; for the wider discipline of patient safety science; and for the meaningful reporting and investigation of patient safety incidents in mental health services. Based on these findings, a new definition of patient safety in mental healthcare is tentatively proposed, which should be further refined in future research: “A framework of organised activities within mental health services that creates the sociotechnical environment to promote recovery and proactively protect against or minimise harms associated with both mental illness and mental healthcare.”
Date of Award1 Jul 2023
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorClaire Henderson (Supervisor) & Nick Sevdalis (Supervisor)

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