The practice of incident reporting and management: current challenges and opportunities for mental health trusts in England

Wood, Douglas; Robinson, Catherine; Nathan, Rajan; McPhillips, Rebecca

doi:10.1108/jmhtep-05-2022-0038

Cited by 3 publications

(2 citation statements)

References 26 publications

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“…The study sample is the same as our study examining patient safety systems (Wood et al , 2023a), but necessary detail concerning the methods is provided here so that this paper can be read on its own and to provide sufficient detail to enable replicability (Leung, 2015). This qualitative interview study aims to build on the findings of our questionnaire study regarding the practice of incident reporting and management (Wood et al , 2023b). Semi-structured interviews were selected as an appropriate method to understand professionals’ perspectives about supporting a patient safety culture in local systems, with a particular focus on improving the effectiveness of serious incident management.…”

Section: Methodsmentioning

confidence: 99%

“…The selected sampling approach was purposive, as this approach provides access to particular perspectives on research areas of interest (Smith et al , 2022). DW reviewed responses from the precursor questionnaire study (Wood et al , 2023b) and selected trust where it was felt that follow-up would provide substantial new insights (Malterud et al , 2016). For example, in the questionnaire study, one participant reported that their trust used a cohort of external investigators to review serious incidents.…”

Section: Methodsmentioning

confidence: 99%

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The art of the possible? Supporting a patient safety culture in mental healthcare to maximise safety

Wood,

Nathan,

Robinson

et al. 2023

MHRJ

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Purpose The current national patient safety strategy for the National Health Service (NHS) in England states that actions need to be taken to support the development of a patient safety culture. This includes that local systems should seek to understand staff perceptions of the fairness and effectiveness of serious incident management. This study aims to explore the perspectives of patient safety professionals about what works well and what could be done better to support a patient safety culture at the level of Trust strategy and serious incident governance. Design/methodology/approach A total of 15 professionals with a role in serious incident management, from five mental health trusts in England, were interviewed using a semi-structured interview guide. Thematic analysis and qualitative description were used to analyse the data. Findings Participants felt that actions to support a patient safety culture were challenging and required long-term and clinical commitment. Broadening the scope of serious incident investigations was felt to be one way to better understand patient safety culture issues. Organisational influences during the serious incident management process were highlighted, informing approaches to maximise the fairness and objectivity of investigation findings. Originality/value The findings of this study offer original insights that the NHS safety system can use to facilitate progression of the patient safety culture agenda. In particular, local mental health trusts could consider the findings in the context of their current strategic objectives related to patient safety culture and operational delivery of serious incident management frameworks.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

The art of the possible? Supporting a patient safety culture in mental healthcare to maximise safety

Wood,

Nathan,

Robinson

et al. 2023

MHRJ

Self Cite

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One size doesn’t always fit all: professional perspectives of serious incident management systems in mental healthcare

Wood,

Robinson,

Nathan

et al. 2023

MHRJ

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Purpose The need to develop effective approaches for responding to healthcare incidents for the purpose of learning and improving patient safety has been recognised in current national policy. However, research into this topic is limited. This study aims to explore the perspectives of professionals in mental health trusts in England about what works well and what could be done better when implementing serious incident management systems. Design/methodology/approach This was a qualitative study using semi-structured interviews. In total, 15 participants were recruited, comprising patient safety managers, serious incident investigators and executive directors, from five mental health trusts in England. The interview data were analysed using a qualitative-descriptive approach to develop meaningful themes. Quotes were selected and presented based on their representation of the data. Findings Participants were dissatisfied with current systems to manage serious incidents, including the root cause analysis approach, which they felt were not adequate for assisting learning and improvement. They described concerns about the capability of serious incident investigators, which was felt to impact on the quality of investigations. Processes to support people adversely affected by serious incidents were felt to be an important part of incident management systems to maximise the learning impact of investigations. Originality/value Findings of this study provide translatable implications for mental health trusts and policymakers, informed by insights into how current approaches for learning from healthcare incidents can be transformed. Further research will build a more comprehensive understanding of mechanisms for responding to healthcare incidents.

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Analysis of England's incident and mental health nursing workforce data 2015–2022

Woodnutt,

Hall,

Libberton

et al. 2024

Psychiatric Ment Health Nurs

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Accessible SummaryWhat is known on the subject? Mental health services report adverse incidents in different ways and the relationship between adverse incidents and the workforce is uncertain. In England, there are national datasets recording all incidents and workforce statistics though there is no peer‐reviewed evidence examining recent trends. What this paper adds to existing knowledge? Although there has been an overall increase in the number of mental health nurses, more are working in the community and the number of nurses relative to adverse incidents has decreased. There have been service‐provision changes but the role of mental health nurses has not significantly changed in this period, and we can therefore assume that their current practice is saturated with risk or increased reporting. To help understand the relationship between nurses and incidents, we need to transform how incidents are recorded in England. What are the implications for practice? English mental health services report greater levels of patient‐related factors such as self‐harm or aggression rather than missed or erroneous care. This makes it difficult to understand if a rise in incident frequency is linked to reporting behaviour, patient risk, unsafe/ineffective care or other reasons and therefore planning workforce deployment to improve care quality is problematic. AbstractIntroductionThere is a paucity of empirical data examining incidents and mental health nurses and the relationship between the two remains uncertain.AimComparison of English national data for incidents and nursing workforce to examine recent trends.MethodDescriptive analysis of two national datasets of incidents and workforce data for England between 2015 and 2022.ResultsA 46% increase in incidents was found; the leading causes are self‐harm and aggressive behaviour. Despite the rise in adverse incident reporting, a 6% increase in mental health nurses was found, with more nurses in community settings than hospitals.DiscussionCurrent services are incident reporting at greater concentrations than in previous years. Patient‐related behaviour continues to be most prominently reported, rather than possible antecedent health services issues that may contribute to reporting. Whilst staffing has increased, this does not seem to have kept pace with the implied workload evident in the increase in incident reports.Implications for PracticeGreater emphasis should be placed on health service behaviour in reporting mechanisms. Self‐harm and aggression should continue to be considered adverse outcomes, but causal health service factors, such as missed care, should be present in pooled reporting to help reduce the occurrence of adverse outcomes.

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The practice of incident reporting and management: current challenges and opportunities for mental health trusts in England

Cited by 3 publications

References 26 publications

The art of the possible? Supporting a patient safety culture in mental healthcare to maximise safety

The art of the possible? Supporting a patient safety culture in mental healthcare to maximise safety

One size doesn’t always fit all: professional perspectives of serious incident management systems in mental healthcare

Analysis of England's incident and mental health nursing workforce data 2015–2022

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