Patient Safety in Mental Health

Wednesday 1st April 2015

Chris Stanbury, Director of Nursing and Governance

What do we mean by ‘patient safety’?Embedding a learning culture in the organisation that

promotes minimising harmful events and reducing the chance of re-occurrence of harmful events.

Implementing systems and processes to identify and manage potential for harm, risks of harm occurring and monitoring harms that do occur – always focussing on co-production and learning lessons.

Ensuring staff have the passion, knowledge, confidence and skills to eliminate/minimise patient harm and maximise patient safety.

Harms in mental healthTangible harms such as falls, physical health

deterioration, health care incidents, health care acquired infections, medication adverse effects and neglect.

Harms associated with mental health such as suicide, para-suicide and self harm.

Harms to others such as verbal and physical aggression, abuse, assault, violence and homicide.

Harder to define harms such as exploitation, vulnerability, loss of dignity/freedom/liberty/control/hope and/or self determination, trauma and psychological injury.

Safety incident management systems

Individual clinical risk management

Engagement and observation

Minimising harm and promoting safety

Learning culture

Learning lessons improvements

Environmental risk management

Co-production and collaboration

Patient Safety in TEWV NHS FT

Patient Safety improvements Board sign up and commitment

Culture of continuous improvement –Kaizen

Staff engagement

Recovery and co-production

User feedback

Estate design

Incident reporting systems

Incident management systems: review and analysis

Patient Safety Project Work

LIPS –violence reduction

Falls Pathway

Learning Lessons

Positive Behavioural Support

Physical Health Care

Suicide Prevention

Force Reduction

Risk Management

Safe Staffing