Understanding adverse incident responses in mental health care : a qualitative study of systems-based patient safety practices

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Challinor, Alexander and Berzins, Kathryn and Bifarin, Oladayo and Anderson, Nina and Xavier, Panchu and Saini, Pooja and Morasae, Esmaeil Khedmati and Nathan, Rajan (2025) Understanding adverse incident responses in mental health care : a qualitative study of systems-based patient safety practices. BMJ Open, 15 (11). e104863. ISSN 2044-6055 (https://doi.org/10.1136/bmjopen-2025-104863)

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Abstract

Background A key part of the patient safety system is how it responds to and learns from safety incidents. To date, there is limited research on understanding system-based approaches to investigating incidents that occur within this complex interacting system. Objectives The aims of this study were to qualitatively explore mental health professionals’ perceptions of patient safety incident investigations; to understand the impact of the transition to systems-based approaches and to explore the influence of different elements of the system on the goals of patient safety. Design, setting and participants The qualitative study involved 19 semi-structured interviews with professionals working within the patient safety system across two mental health National Health Service trusts. The data were analysed using thematic analysis. Results Those interviewed identified that a change in approach to incident investigation, from root cause analysis to systems-based, would lead to rigorous investigations that are effectively linked to learning. Over time, this was described as a contributory factor to reducing feelings of blame and positively influencing safety culture. There were considerations of potential negative effects from a systems-based approach, such as the shifting rather than elimination of blame, and the possibility of missing individual poor practice. The findings identify the presence of several interdependencies across the system that could have a positive or negative influence on the outcomes of incident responses. Conclusions This study demonstrates that the interdependencies within the system and our limited understanding of safety in mental healthcare introduces complexity and uncertainty to incident investigation outcomes. This is likely to impact on safety incident responses and learning, where acknowledging and evaluating this complexity is likely to reduce any potential negative outcomes that exist.

ORCID iDs

Challinor, Alexander, Berzins, Kathryn, Bifarin, Oladayo, Anderson, Nina, Xavier, Panchu, Saini, Pooja, Morasae, Esmaeil Khedmati ORCID logoORCID: https://orcid.org/0000-0003-2172-9653 and Nathan, Rajan;
CORE (COnnecting REpositories)