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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| Format: | Article |
| Language: | English |
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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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| _version_ | 1823860905693151232 |
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| author | Helen Haylor Tony Sparkes Gerry Armitage Melanie Dawson-Jones Keith Double Lisa Edwards |
| author_facet | Helen Haylor Tony Sparkes Gerry Armitage Melanie Dawson-Jones Keith Double Lisa Edwards |
| author_sort | Helen Haylor |
| collection | DOAJ |
| description | 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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| format | Article |
| id | doaj-art-7cec45a0fa644f65932c65b451ab2491 |
| institution | Kabale University |
| issn | 2056-4694 2056-4708 |
| language | English |
| publishDate | 2025-02-01 |
| publisher | Cambridge University Press |
| record_format | Article |
| series | BJPsych Bulletin |
| spelling | doaj-art-7cec45a0fa644f65932c65b451ab24912025-02-10T09:26:20ZengCambridge University PressBJPsych Bulletin2056-46942056-47082025-02-0149233510.1192/bjb.2023.98The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesisHelen Haylor0Tony Sparkes1https://orcid.org/0000-0001-6007-9572Gerry Armitage2Melanie Dawson-Jones3https://orcid.org/0009-0004-6269-2927Keith Double4Lisa Edwards5First Response Crisis Service, Bradford District Care NHS Foundation Trust, UKFaculty of Management, Law and Social Sciences, University of Bradford, UKResearch and Development Department, Bradford District Care NHS Foundation Trust, UK Faculty of Health Studies, University of Bradford, UKLibrary and Health Promotion Resources Centre, Bradford District Care NHS Foundation Trust, UKPatient and Carer Experience and Involvement Team, Bradford District Care NHS Foundation Trust, UKFaculty of Health Studies, University of Bradford, UKAims 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. https://www.cambridge.org/core/product/identifier/S2056469423000980/type/journal_articleSuicidecommunityserious incident investigationorganisational learningpatient context |
| spellingShingle | Helen Haylor Tony Sparkes Gerry Armitage Melanie Dawson-Jones Keith Double Lisa Edwards The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis BJPsych Bulletin Suicide community serious incident investigation organisational learning patient context |
| title | The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis |
| title_full | The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis |
| title_fullStr | The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis |
| title_full_unstemmed | The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis |
| title_short | The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis |
| title_sort | process and perspective of serious incident investigations in adult community mental health services integrative review and synthesis |
| topic | Suicide community serious incident investigation organisational learning patient context |
| url | https://www.cambridge.org/core/product/identifier/S2056469423000980/type/journal_article |
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