Patient safety in mental health care – considerations for clinicians
‘Patient safety’ is an important (and topical) subject in all settings, with health departments of the respective UK governments repeatedly highlighting how the development of a patient safety culture across the NHS is vital. The publication of the report into the Mid-Staffordshire failings and the Berwick review in 2013 have both brought into sharp focus the need for a ‘safety’ to be at the top of the agenda for healthcare providers. It’s clear that many NHS organisations are able to demonstrate improvements, and the emphasis on developing a safety culture is bringing benefits; but a review of the key safety domains for healthcare providers in England, shows that there is still much to do.
There is an understandable emphasis on some relatively obvious domains – safe staffing levels, infection prevention and control, safe surgical technique, and a robust incident-reporting culture – among others.
But what about patient safety in mental health care? How do mental health nurses and other practitioners apply these principles to their own setting, and what constitutes the basics of ‘patient safety’ in mental health?
Along with a number of other colleagues we have used the patient safety agenda to help promote and share a suicide prevention culture across a large NHS mental health trust, and this work has helped us to think about its application outside of the more traditional areas identified above. We have used the patient safety message as a way of addressing suicide prevention, building on the emerging evidence which suggests that organisations with a strong patient safety culture have fewer serious untoward incidents, including unexpected deaths.
Our work has helped us develop a patient safety agenda to support suicide prevention, and as a result we have developed practical guidance for mental health clinicians. Here are examples of how we have framed and communicated the key messages, which I hope will also be of value to colleagues in other mental health settings.
Patient safety tips for suicide prevention:
- Be clear about diagnosis and formulation
Clarity regarding diagnosis, assessment of the person’s needs and a working formulation of the nature and context of their problems, means that accurate risk assessment and care planning can occur. Remember, that it is also equally important to be clear with the service user and their carer/family member about diagnosis and formulation.
- Target treatment on the priority problem – with clear goals
Care planning and interventions should focus on the priority problem, or problems, and you need to set clear goals or aims in relation to this. Check that you have achieved some form of concordance with the person about the priority problem – do they agree with your assessment/formulation, and are they willing and able to work with you in managing risk?
- Talk to relatives/carers about risk
Relatives and carers have a major role to play in relation to the assessment and management of risk. As well as acting as a source of valuable information that can inform accurate risk assessment, they will need to be aware of the plans made to manage the risks identified. This is particularly important for community-based teams and services, where the person is being cared for at home, and their family member may be responsible for providing the bulk of the person’s informal care.
- Be alert to changing risk
Risk, by its very nature, is a dynamic concept, and the level and degree of risk demonstrated by the person can vary from moment to moment. When planning and implementing risk management interventions, take account of the factors, circumstances or situations that can cause the person’s risk profile to fluctuate.
- Be alert to risk at times of transition
When service users are required to deal with and respond to transitions, then the level of risk can increase. Such transitions may include handovers of care from one team or service to another, discharge from a part of the service (in particular, discharge from inpatient care), and personal and interpersonal transitions or life events, such as bereavement and unemployment.
- Identify and work with hopelessness
Individuals who express feelings of hopelessness and helplessness are at increased risk of suicide. Address this issue explicitly, talk to the person (and carer, if appropriate) about it directly. Identifying hopelessness can only be achieved by accurate and sensitive assessment and risk formulation practice.
- Take seriously previous attempts using high lethality methods
Data and experience show that people who have acted on suicidal thoughts using violent methods (such as the use of weapons, jumping from a height, and hanging) are most likely to be at increased risk.
- Look at all risk indicators – not just stated intent
Consider ALL risk factors when planning risk management interventions; treat with caution statements by the person that they have no plans to kill themselves, particularly when working with those people who have a number of other suicide risk characteristics.
- Access as much of the record as possible
Key assessment and risk management information may be contained in previous health and social care records (including those records held by other care providers, such as GPs). Make all reasonable attempts to obtain this information as a way of informing assessment and care planning processes.
- Engagement, Engagement, Engagement!