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PATIENT SAFETY IN MENTAL HEALTHKey Informant InterviewsThe telephone interviews were conducted with 19 key informants in patient safety and/or mentalhealth. The interviews sought information on current initiatives and research; strategies for improvingpatient safety; emerging issues; gaps in current knowledge and practice; and barriers to improvingpatient safety. The interviews were recorded, transcribed, and qualitatively analyzed. The analysis involved a two-step process: 1) coding each interview on issues that were easily categorized and that couldprovide some basic quantitative data, and 2) identifying larger themes that emerged from the data.Roundtable EventSeventy two professionals with expertise in patient safety and mental health attended and participated in an invitational Roundtable Event held on September 18, 2008, in Toronto, Ontario. Participants explored three topics in small discussion groups of 8-10 people. Each group had a facilitatorand scribe. The scribe notes from the small group discussions formed data for a qualitative analysis.The analysis involved a two-step process: 1) identifying common themes from each discussion topic,and 2) organizing and categorizing the information from each group under each of the identifiedthemes.FindingsSeveral findings emerged from the research pertaining to planning and policy, practice, and research.The findings suggest that national leadership and advocacy for patient safety in mental health isrequired to champion the cause. Also required is a framework or patient safety strategy which considers the unique concerns related to mental health care across Canada, including the standardizationof patient safety terminology and nomenclature, practices, reporting mechanisms, and policies. Asa first step, however, a relative consensus on what falls under the purview of patient safety in mentalhealth is needed in order to develop concise, workable solutions with clear objectives.In order for patient safety in mental health settings to improve, a culture of safety needs to be embedded within all levels of an organization. A safety culture would include the adoption of a systems levelapproach and inclusion of staff and patients in the examination of patient safety incidents. It wouldallow patients and their family/caregivers to play a more active role in decision making, patient care,risk assessment and safety interventions. A just culture accepts that discrimination and marginalization of people with mental illness undermines access to care, quality and safety of care, and healthoutcomes and seeks to eliminate the stigma against people with mental illness.Advancing safer patient care practices in mental health settings requires effective communication,service integration, and inter-professional collaboration, especially during transitions of care. It alsorequires the use of empirically-validated and consistently accepted tools and training and educationprograms to develop and implement evidence-based patient safety interventions. To develop thisevidence, research funds need to be available to attract high quality researchers who can develop andimplement rigorous research methodologies.

Understanding Patient Safety in Mental HealthBackgroundEveryday a large number of patients are treated and caredfor without incident by medical practitioners worldwide.However, incidents such as medication adverse events,misdiagnosis, and slips and falls do occur during thecourse of medical care, placing patients at risk for injuryand harm. Since the Institute of Medicine published itsseminal report To Err is Human: Building a Safer HealthSystem (Kohn, Corrigan, & Donaldson, 1999) underscoring the magnitude to which medical errors contribute tomortality and morbidity within the United States healthcare system, health organizations globally have been galvanized to develop and establish best practices in patientsafety, giving rise to the development and instigation ofincident reporting systems, and policies and proceduresamong service providers. One key indicator for patientsafety is the rate of adverse events among hospital patients.Adverse events are unintended injuries or complicationsthat are caused by health-care management, rather thanby the patients’ underlying diseases. They lead to patientinjuries, disability, prolonged hospital stays, and even lossof life (Baker et al., 2004). The Canadian Adverse EventsStudy found that 7.5% of patients admitted to acute carehospitals in 2000 experienced at least one adverse event,36.9% of which were judged to be highly preventable(Baker et al., 2004).Although many of the same patient safety risk factorsthat exist in medical settings apply to mental health settings, there are unique patient safety issues that arise inthe mental health context that are either more commonamong individuals with mental illness or are atypical ofthose arising in acute medical care. Some of these includepatient safety issues around seclusion and restraint use,self-harming behaviour and suicide, absconding, and reduced capacity for self-advocacy. At the moment there isa lack of readily available information regarding the typesof incidents and causes of adverse events in the treatmentof patients with mental health disorders in Canadianmental health care. This gap is surprising given that someof the highest rates of adverse medication events reportedin studies comparing various health care settings were ininpatient psychiatric units (e.g., Bates, 2003).Due to this knowledge gap, there is little scientific literature and sound evidence to guide health system poli cies and practices for the safe delivery of care in mentalhealth settings. As such, the Ontario Hospital Association(OHA) and Canadian Patient Safety Institute (CPSI)jointly commissioned a research team through a competition process from British Columbia Mental Health andAddiction Services (BCMHAS) to develop a backgroundpaper that concentrates on the issues of patient safety inmental health settings. The paper includes an in-depthreview of the white and grey literature, analysis of interview data collected during a series of structured telephoneinterviews, and analysis of small group discussions during an invitational Roundtable Event. The paper wasproduced with guidance and coordination from OHA,CPSI, and a Pan-Canadian Mental Health and PatientSafety Advisory Committee (Advisory Committee).For the purposes of this document, mental health wasconfined to those diagnoses covered in the Diagnosticand Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, American PsychiatricAssociation [APA], 1997). Patient safety at the primary,secondary, and tertiary care levels was examined withconsideration to hospital, private sector, and other community-based mental health services. Patient safety inmental health across the lifespan, including child andyouth, adult, and older adult populations, were explored.It is acknowledged that there is debate in the literatureabout the appropriate term to refer to individuals withmental illness who use health-care services. The termsmental health service users, consumers, clients, and patients are often used interchangeably in the literature andin clinical practice. For clarity, in this report the termpatient is used.Issues in Defining PatientSafety in Mental HealthPatient safety in mental health settings has only recentlybeen considered as a field of study or a focus in the patientsafety literature in its own right and is even less frequentlydefined. It is often subsumed under the broader conceptof patient safety with no argument having been set forward to define it separately. A review of the literaturerevealed that attempts to understand and define patientsafety in the mental health context often are left to drawfrom the larger literature on patient safety in general.

PATIENT SAFETY IN MENTAL HEALTHAlthough white and grey literature offer many differentdefinitions of patient safety, no single definition has beenadopted universally and hence the field is thought to sufferfrom this lack of a common nomenclature (Chang, Schye,Croteau, O’Leary, & Loeb, 2005; Kohn et al., 1999; National Steering Committee on Patient Safety, 2002). Further complicating this picture is the need to define notonly patient safety but also the related terms: patient safetyincidents, adverse events, and close calls (near misses).A shared definition of patient safety is lacking acrossCanada (Baker et al., 2007). The Canadian Patient SafetyDictionary (Davies, Hébert, & Hoffman, 2003), developed in response to an identified need for a common language of patient safety, recommends “that patient safetybe defined as the reduction and mitigation of unsafe actswithin the health care system, as well as through the use ofbest practices shown to lead to optimal patient outcomes.”However, national and international advancements inknowledge and understanding of patient safety conceptsand the need for consistency and clarity across settings,has prompted a re-examination of the definitions andterms used. The World Health Organization’s (WHO)International Classification for Patient Safety initiative:“aims to define, harmonize and group patientsafety concepts into an internationally agreedclassification. This will help elicit, capture andanalyze factors relevant to patient safety in amanner conducive to learning and system improvement. The classification aims to be adaptable yet consistent across the entire spectrum ofhealth care and across cultures and languages”(2008, para. 2).WHO (2007) created a Conceptual Framework for theInternational Classification for Patient Safety, which is currently in field-testing. It represents a consensus of international experts and up-to-date information on patientsafety within the health care context across the world,including mental health settings and patients. The language and definitions throughout this paper are thereforein alignment with the WHO’s framework.A patient safety incident is defined as “an event or circumstance which could have resulted, or did result, in unnecessary harm to a patient, and has a more constrainedmeaning than the term incident which, when used in ageneral context, has a wider meaning as an event or circumstance which could have resulted, or did result, inharm to any person and/or a complaint, loss or damage”(WHO, 2007, p.7).An adverse event is “an incident which results in harmto a patient” (WHO, 2007, p.7). Harm is considered anoutcome that negatively affects a patient’s health and/orquality of life, including illness, injury, suffering, disability, and death, and may thus be physical, social, orpsychological (WHO, 2007).A close call (also known as a near miss) is an incidentthat occurs that has the potential to result in harm butfails to do so either by chance or by timely intervention(WHO, 2007).Issues in Calculating PatientSafety Incident Rates inMental HealthBowers (2000) highlighted a related problem that plaguesthe mental health patient safety literature; inconsistenciesin calculating incident rates. He described five possiblemethods of calculating incident

British Columbia Mental Health and Addiction Services Tonia L. Nicholls, Ph.D. Michael Smith Foundation for Health Research Career Scholar British Columbia Mental Health and Addiction Service Ric M. Procyshyn, Pharm.D., Ph.D. Research Psychopharmacologist British Columbia Mental Health and Addiction Services Carla McLean, M.A. (Ph.D. Student)