Data presented here is generated from all Severity Assessment Code 1 (SAC1) mental health clinical incidents that were analysed and reported to PSC in 2008. This data is not aligned with the reporting period for this edition of Learning to Action (being aligned with a calendar year rather than a financial year), but is included here because the findings and analysis can be validly generalised.
Information includes:
types of clinical incident analysis methodology employed
recommendation themes
the (de‐identified) recommendations by clinical category
Methodology
For suspected suicides of mental health consumers receiving inpatient care (this includes care provided in the Emergency Department and inpatient consumers who have died while on approved leave or absconding from an inpatient unit), the mandatory incident analysis methodology is Root Cause Analysis (RCA).
RCA is not mandatory when the SAC1 event pertains to the suspected suicide of a consumer under the care of a community mental health service. When a RCA is not carried out, some other form of clinical incident analysis such as a Human Error and Patient Safety (HEAPS) analysis takes place.
In 2008, the Patient Safety Centre received notification of 79 mental health SAC1 events. Three of these notifications pertained to incidents which occurred in 2007. The incidents reported fall under the following clinical categories:
Figure 58: Categories of Mental Health SAC 1 Events ‐ 2008
Clinical Category
Number
of SAC1
Suspected suicide in the community of a person under the care of a mental health service
52 Suspected suicide of a patient receiving inpatient healthcare – death occurred in a mental health facility
1 Suspected suicide of a patient receiving inpatient healthcare – death occurred during approved leave
3 Suspected suicide of a patient receiving inpatient healthcare – death after absconding
6 Other (suspected suicide unless otherwise indicated):
Cause of death uncertain ‐ ? suicide or natural causes 1 Cause of death uncertain ‐ ? suicide or accident 1 Cause of death uncertain ‐ ? suicide or over dose 1 Episode of care uncertain ‐ ? patient open or closed to MHS 2 Pt was closed to service but discharged within 30 days of
death
1 Patient was awaiting assessment 2 Patient alleged to have committed homicide 1
9
Total In‐Scope Suspected suicides 71
Figure 59: Incidents reported, but out of Scope for analysis
Incidents reported and out of scope for this report
Death later determined not to be suicide (4) 4 Patient was not a MHS consumer (2) 2 Patient closed to MHS more than 30 days before death (1) 1 Incident involved a siege – no death (1) 1
Total out of scope reported events: 8
Of the 71 Mental Health SAC1 incidents that were considered for this study, 63% (n = 45) had incident analysis reports submitted to the PSC by July 1st 2009.
The incident analysis methodology used to review the 45 MH SAC1 incidents was as follows:
Figure 60: Analysis Methods for Mental Health SAC 1 events
Analysis Type Count %
RCA 18 40%
HEAPS 10 22.2%
Critical Incident R/V using known incident analysis structure 10 22.2% Critical Incident R/V using unknown incident analysis
structure
5 11.1% RCA process cancelled (no further information) 2 4.5%
Total 45 100%
Findings
A total of 152 recommendations were considered in this study. If a given recommendation was repeated in subsequent clinical incident analyses in the same district, the recommendation was only counted once. The recommendations can be classified under the following themes:
Figure 61: Themes identified in Recommendations about Mental Health
Events
Theme
Continuity of care This includes: handover; transfer processes; discharge planning
and processes, follow up care; and, communication among
staff / care providers.
Workforce Issues.
This includes: training; education; orientation; supervision;
staffing levels; workload; skill mix; rostering; scope of practice;
staff roles; credentialing; fatigue; and, team composition
Policies and procedures.
This includes the development, review, implementation and
oversight of: policies; procedures; protocols; workplace
instructions; guidelines; clinical pathways; and, workplace
practice instructions not otherwise specified.
Documentation, Including medical records, electronic clinical information
systems.
Assessment Includes particular reference to risk assessment and screening.
Emergency Department. Relates to care in emergency departments.
Capital works Modification of environment / equipment and number of beds.
Dual diagnosis and
management of drug and
alcohol issues.
MHA2000.
Other.
These are recommendations which are specific to the
particular incident under review and which do not fit well into
any of the other prevalent categories
Medication.
Figure 62: Frequency of Themes identified in Recommendations about
Mental Health Events
Recommendation Theme # of times
Theme counted % of times theme was counted Continuity of care 68 22% Workforce issues 58 19%
Policies and procedures 56 18%
Documentation, medical records, electronic clinical information systems
38 12%
Assessment 31 10%
Emergency Department 18 6%
Capital works / Environment / Equipment and Bed numbers
9 3%
Dual diagnosis and management of drug and alcohol issues.
9 3%
MHA2000 8 3%
Other 7 2%
Medication 6 2%
Total number of themes counted: 308 100%
Discussion
It is useful to analyse the recommendations that have been made following clinical incident analysis. The primary use of this information is to assist health service providers, managers and policy makers to see where gaps in safe service delivery exist; and then to respond to these issues to reduce preventable patient harm. Additionally, it is expected that this information will be used as a reference during clinical incident review when working with clinical incident analysis teams. Many districts encounter the same sorts of incidents. It can be validating to see that other districts are choosing to employ similar strategies to address problems identified. It can also be inspiring to see an innovative approach which has not been tried earlier and which may be applicable to one’s own service. The sharing of this information will assist in planning for improved, safer, evidence based mental health service delivery.
Outcome from Incident Review:
Incident review using known incident analysis methodology / structure (RCA, HEAPS or critical incident review which includes breakdown of HEAPS factors) yielded recommendations or lessons learnt at least 90% of the time. Use of an unknown
incident analysis methodology (a RCA or HEAPS was not conducted and no information is provided regarding what type of incident analysis took place other than that a clinical or incident review occurred) yielded recommendations or lessons learnt 20% of the time. This is an issue for consideration by mental health services when determining the type of incident methodology to employ when reviewing the suspected suicide of consumers under the care of a community mental health service, where RCA is not mandatory.
For the future
While the information presented above is interesting, it is of limited utility. For example, this information does not indicate whether the recommendations were implemented or not, and if so, whether they made a difference. This “closing of the loop” information is what is needed to develop an evidence base regarding what makes mental health care safe.