AuthorsTracey A. Brickell, D.Psych.Patient Safety in Mental Health Research Project LeadBritish Columbia Mental Health and Addiction ServicesTonia L. Nicholls, Ph.D.Michael Smith Foundation for Health Research Career ScholarBritish Columbia Mental Health and Addiction ServiceRic M. Procyshyn, Pharm.D., Ph.D.Research PsychopharmacologistBritish Columbia Mental Health and Addiction ServicesCarla McLean, M.A. (Ph.D. Student)Qualitative Analysis SpecialistBritish Columbia Mental Health and Addiction ServicesRebecca J. Dempster, Ph.D.Clinical Research ConsultantBritish Columbia Mental Health and Addiction ServicesJennifer A. A. Lavoie, M.A. (Ph.D. Student)Research OfficerBritish Columbia Mental Health and Addiction ServicesKimberly J. Sahlstrom, M.A.Research Officer / CoordinatorBritish Columbia Mental Health and Addiction ServicesTodd M. Tomita, M.D., FRCPCConsulting PsychiatristBritish Columbia Mental Health and Addiction ServicesEugene Wang, M.D., FRCPCConsulting PsychiatristBritish Columbia Mental Health and Addiction ServicesSuggested citation:Brickell, T. A., Nicholls, T. L., Procyshyn, R. M., McLean, C., Dempster, R. J., Lavoie, J. A. A., Sahlstrom, K. J.,Tomita, T. M., & Wang, E. (2009). Patient safety in mental health. Edmonton, Alberta: Canadian Patient SafetyInstitute and Ontario Hospital Association.The Canadian Patient Safety Institute would like to acknowledge funding support from Health Canada. The viewsexpressed here do not necessarily represent the views of Health Canada.ISBN: 978-1-926541-06-8

PATIENT SAFETY IN MENTAL HEALTHAcknowledgementsBritish Columbia Mental Health and Addiction ServicesBrooke Ballantyne-Scott and Suzana Mitrovic for their assistance in developing and coordinating theliterature review. Kristen Howard for scheduling and conducting the informant interviews. Alina Bonci,Anna Warner, and Kimberly McIntosh for performing the literature searches. Katherine Rossiter for herassistance with the interview questions.Canadian Patient Safety Institute (CPSI) and Ontario Hospital Association (OHA)Orvie Dingwall (CPSI) for her expertise in developing and conducting the literature review. Sandi Kossey(CPSI), and Dominique Taylor, Cyrelle Muskat, Michelle Caplan and Deborah Cumming (OHA) for theirassistance in developing the research and editing the paper.Pan-Canadian Mental Health and Patient Safety Advisory Committee Chair, Glenna Raymond, President and Chief Executive Officer, Whitby Mental Health Centre Lynda Bond, Director, Quality, Safety and Performance Improvement, BC Mental Health andAddiction Services Michelle Caplan, Policy Analyst, Policy, Legislative & Legal Affairs, Ontario Hospital Association Dr. Linda S. Courey, Director, Mental Health Services, Cape Breton District Health Authority Deborah Cumming, Policy Analyst, Policy, Legislative & Legal Affairs, Ontario Hospital Association Orvie Dingwall, Librarian and Project Manager, Canadian Patient Safety Institute Pat Fryer, Consultant, Patient Safety, Risk Management, and Quality; Chair, Ontario Health CareRisk Management Network Sandi Kossey, Project Manager, Canadian Patient Safety Institute Marie Owen, Director of Operations, Canadian Patient Safety Institute Elaine Santa Mina, Associate Professor, School of Nursing, Ryerson University Cyrelle Muskat, Consultant, Patient Safety and Clinical Best Practice, Ontario Hospital Association Dominique Taylor, Consultant, Patient Safety and Clinical Best Practice, Ontario Hospital Association Dr. George D. Watson, Executive Medical Director, Alberta Mental Health Board Cheryl Williams, Program Director, Mental Health and Emergency Services, Rouge Valley Health System

Table of ContentsTable of Contents.4Executive Summary.6Understanding Patient Safety in Mental Health.8Background.8Issues in Defining Patient Safety in Mental Health.8Issues in Calculating Patient Safety Incident Rates in Mental Health.9Patient Safety Incidents in Mental Health.9Contributing Factors.11Patient Factors.12Provider Factors.12Organizational Factors.12Physical Environment.13The Relationship Between Patient Safety and Employee Safety.13National Initiatives Influencing Patient Safety.14Discussion.14Literature Review.15Background.15Included and Excluded Patient Safety Incidents.15White Literature Search Strategy.15Grey Literature Search Strategy.15Patient Safety Incidents Reviewed.16Violence and Aggression.16Patient Victimization.16Suicide and Self-Harm.17Seclusion and Restraint.18Falls and Other Patient Accidents.19Absconding and Missing Patients.20Adverse Medication Events.20Adverse Diagnostic Events.21Gaps in the Literature.22High Quality Research.22Canadian Perspective.22Understudied Populations.22Understudied Mental Health Sectors.22Patient’s Perspective.22Psychological and Emotional Harm.22Risk Assessment, Training, and Intervention.22Discussion.23Key Informant lts.25Defining the Issue, Recognizing Unique Barriers, and Setting Priorities.25Priority Issues - Adverse Events, Service Availability, and Quality of Care.25Responding to Patient Safety - Current Practices and Initiatives.25Knowledge Transfer from Other Health Care Settings.26Improvements, Barriers, and Challenges.26

PATIENT SAFETY IN MENTAL HEALTHDiscussion.27Roundtable 9Discussion Topic 1: ‘What are the themes, priority issues, and actions for patientsafety in mental health?’.29Stigma.29Access to Care.29Patient Voice or Involvement.29Standardization of Definitions, Nomenclature, Measurement, and Practice.30Communication, Service Integration, and Inter-Professional Collaboration.30Promoting a Patient Safety Culture.30Adverse Events and the Growing Complexity of Mental Health Patients.30Discussion Topic 2: ‘What best practices, tools, programs and initiatives are currentlybeing utilized to optimize patient safety for patients receiving mental health services?’.30Discussion Topic 3: ‘What are the next steps/future directions for patient safetyin mental health?’.31Action at the National Level.31Leadership.31Research and Evaluation.31Patient and Family Involvement.32Education.32Funding.32Expanding the Breadth of Patient Safety.32Discussion.32Findings and Emerging Themes.33Planning and ix A: White Literature Search Strategy.36Mental Health and Patient Safety Search Results.36Medline Search Strategy (April 9, 2008) n 2,561.37PsycINFO Search Strategy (April 21, 2008), n 972.42Embase Search Strategy (May 4, 2008), n 1,643.43CINAHL Search Strategy (May 14, 2008), n 1,057.44Appendix B: Websites Searched.46Appendix C: Sample Spreadsheet.48Appendix D: Key Informant Interview Questions.50Appendix E: Breakout Discussions Participant Guide.51Appendix F: Key Informants and Roundtable Participants.52References.55

Executive SummaryBackgroundEveryday a large number of patients are treated and cared for without incident by health care practitioners worldwide. Like other high risk industries (e.g., aviation and nuclear power), safety incidentsoccur during the course of medical care, placing patients at risk for injury or harm. In health care,much of the literature, and consequently our understanding of patient safety, has come from acutecare medical settings. Although many of the patient safety risk factors that exist in medical settingsalso apply to mental health settings, there are unique patient safety issues in mental health that aredifferent to those in medical care. Seclusion and restraint use, self-harming behaviour and suicide,absconding, and reduced capacity for self-advocacy are particularly prominent to mental health patients. Both the patient population and the environment make patient safety in mental health unique.In some circumstances, the uniqueness is associated more with the diagnosis and patient populationthan with the mental health setting, and in other circumstances the uniqueness is related more to thesetting than the patient population or diagnosis.It is only recently that patient safety in mental health was considered a field in its own right and assuch, there is a lack of awareness of the issues as well as a shortage of research and readily availableinformation to guide patient safety systems, practices, policies, and care delivery in mental health.Work is required to establish a clear definition, set priorities, and develop strategies for respondingto patient safety concerns.Recognizing this knowledge gap, the Ontario Hospital Association and Canadian Patient SafetyInstitute jointly commissioned a research team through a competition process from British ColumbiaMental Health and Addiction Services to develop a background paper outlining current issues inpatient safety across mental health settings. The background paper includes three methodologies: 1)an in-depth review of the white and grey literature; 2) an analysis of interview data collected duringa series of telephone interviews; and 3) an analysis of small group discussions during an invitationalRoundtable Event held in Toronto, September 2008.In this paper, mental health was defined by those diagnoses in the Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, American Psychiatric Association[APA], 1997). Patient safety across the following areas was considered: a) primary, secondary, andtertiary care levels; b) hospital, private sector, and other community-based mental health services; andc) child and youth, adult, and older adult populations.Literature SearchThe white literature was searched in four electronic databases (Medline, CINAHL, Embase, andPsycINFO) and the grey literature through sixty-six websites (Canadian/international patient safety,mental health, government health care, and library websites). Approximately 1500 papers were reviewed. The review of literature focused on eight key patient safety incidents including: violence andaggression; patient victimization; suicide and self-harm; seclusion and restraint; falls and other patient accidents; absconding and missing patients; adverse medication events; and adverse diagnosticevents. Excluded areas included: patient safety incidents in persons with mental illness receiving careoutside the mental health sector; privacy violations; documented adverse effects of specific medications; medical equipment failure not specific to mental health settings; and infectious disease.

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)