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Quality improvement and patient safety in psychiatry
Also known as Clinical governance mental health · Patient safety psychiatry · QI PDSA psychiatry · Human factors mental health · Just culture psychiatry · Safewards quality improvement · Serious incident review mental health · Donabedian structure process outcome
Exam-exhaustive fellowship topic on quality improvement and patient safety in psychiatry: Donabedian measures, Model for Improvement/PDSA, systems thinking and Swiss-cheese human factors, just culture, psychiatry-specific harm domains, Safewards and suicide-prevention service design, measurement (outcome/process/balancing), RCA pitfalls, and regional governance frames (ACSQHC/NICE/APA). FRANZCP-primary, globally tagged.
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Red flags
- Blame-first response to error that suppresses reporting and learning
- Calling a one-off audit 'QI' with no aim, measures, or PDSA cycles
- Gaming metrics (reclassifying seclusion, hiding near misses)
- Ignoring post-discharge and post-contact suicide risk windows in service design
- Safewards or seclusion-reduction branding without fidelity or data
- Physical-health monitoring failures for high-risk psychotropics treated as optional
Meet the patient
A 38-year-old man discharges himself from your acute ward forty minutes after a frustrated PRN discussion. Forty-eight hours later he is dead. The morning huddle had flagged his leave as low risk, his crisis plan was not yet on the electronic record, and the family carer alert was never sent. Nobody was malicious; several people were tired, and the system handed them a trap.[2][10]
Every registrar reaches for "was the risk assessment wrong?" The fellowship question is sharper: "Was this a person problem or a system problem — and what would you change before the next admission?" That is the whole topic, and the answer is almost never "retrain the registrar".[2][11]
References14ShowHide
- [1]Donabedian A Evaluating the quality of medical care Milbank Mem Fund Q, 1966.PMID 5338568
- [2]Reason J Human error: models and management BMJ, 2000.PMID 10720363
- [3]Leape LL Error in medicine JAMA, 1994.PMID 7503827
- [4]Berwick DM Continuous improvement as an ideal in health care N Engl J Med, 1989.PMID 2909878
- [5]Vincent C, Neale G, Woloshynowych M Adverse events in British hospitals: preliminary retrospective record review BMJ, 2001.PMID 11230064
- [6]Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU N Engl J Med, 2006.PMID 17192537
- [7]Bowers L Safewards: a new model of conflict and containment on psychiatric wards J Psychiatr Ment Health Nurs, 2014.PMID 24548312
- [8]Bowers L, James K, Quirk A, et al. Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial Int J Nurs Stud, 2015.PMID 26166187
- [9]While D, Bickley H, Roscoe A, et al. Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional before-and-after observational study Lancet, 2012.PMID 22305767
- [10]Appleby L, Shaw J, Amos T, et al. Suicide within 12 months of contact with mental health services: national clinical survey BMJ, 1999.PMID 10231250
- [11]Thibaut B, Dewa LH, Ramtale SC, et al. Patient safety in inpatient mental health settings: a systematic review BMJ Open, 2019.PMID 31874869
- [12]Silver SA, Harel Z, McQuillan R, et al. How to Begin a Quality Improvement Project Clin J Am Soc Nephrol, 2016.PMID 27016497
- [13]Grasso BC, Rothschild JM, Genest R, Bates DW What do we know about medication errors in inpatient psychiatry? Jt Comm J Qual Saf, 2003.PMID 12953603
- [14]Hunt IM, Windfuhr K, Shaw J, et al. Ligature points and ligature types used by psychiatric inpatients who die by hanging: a national study J Affect Disord, 2012.PMID 22343063