The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis.

ABSTRACT:

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 suicid

SUBMITTER: Haylor H 

PROVIDER: S-EPMC11810474 | biostudies-literature | 2024 Jan

REPOSITORIES: biostudies-literature