The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis
Aims and method Serious incident management and organisational learning are international patient safety priorities. Little is known about the quality of suicide investigations and, in turn, the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, p...
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| Main Authors: | , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Cambridge University Press
2025-02-01
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| Series: | BJPsych Bulletin |
| Subjects: | |
| Online Access: | https://www.cambridge.org/core/product/identifier/S2056469423000980/type/journal_article |
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| Summary: | Aims and method
Serious incident management and organisational learning are international patient safety priorities. Little is known about the quality of suicide investigations and, in turn, the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time.
Results
Recent literature proposes a Safety-II approach in response to the limitations of RCA. The importance of applying these approaches within a mental healthcare system that advocates a zero suicide framework, grounded in a restorative just culture, is highlighted.
Clinical implications
Although integrative reviews and syntheses have clear methodological limitations, this approach facilitates the management of a disparate body of work to advance a critical understanding of patient safety in adult community mental healthcare.
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| ISSN: | 2056-4694 2056-4708 |