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

作者：Phoebe Averill, Nick Sevdalis, Claire Henderson · 发表于：Psychological Medicine · 年份：2025 · DOI：10.1017/s0033291724003532 · 被引用次数：3 · 研究领域：Patient Safety and Medication Errors、Workplace Violence and Bullying、Healthcare Decision-Making and Restraints

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 ...