ArticlePsychological medicine2025
Patient safety incidents within adult community-based mental health services in England: A mixed-methods examination of reported incidents, contributory factors, and proposed solutions.
Article in Psychological medicine, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers.
What it found
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Who cites it
3 citing papers in PubMed.
- From Root Cause Analysis to Systems Thinking: A Comparative Content Analysis of Patient Safety Incident Investigation Reports in Mental Healthcare.Journal of evaluation in clinical practice · 2026Article
- Patient safety incidents in mental health residential services: a multicenter, crosssectional, survey-based study.Frontiers in psychiatry · 2026Article
- Institutional Abuse, Neglect and Harm in UK Community Mental Health Services: A Scoping Review of the Peer-Reviewed Evidence.Health expectations : an international journal of public participation in health care and health policy · 2025Article
Corrections and comments
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Authors and funding
3 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundRelatively little is known about mental healthcare-related harm, with patient safety incidents (PSIs) in community-based services particularly poorly understood. We aimed to characterize PSIs, contributory factors, and reporter-identified solutions within community-based mental health services for working-age adults.
methodsWe obtained data on PSIs reported within English services from the National Reporting and Learning System. Of retrieved reports, we sampled all incidents reportedly involving 'Death', 'Severe harm', or 'Moderate harm', and random samples of a proportion of 'Low harm' or 'No harm' incidents. PSIs and contributory factors were classified through qualitative content analysis using existing frameworks. Frequencies and proportions of incident types were computed, and reporter-identified solutions were inductively categorized.
resultsOf 1825 sampled reports, 1443 were eligible and classified into nine categories. Harmful outcomes, wherein service influence was unclear, were widely observed, with self-harm the modal concern amongst 'No harm' (15.0%), 'Low harm' (62.8%), and 'Moderate harm' (37.6%) categories. Attempted suicides (51.7%) and suicides (52.1%) were the most frequently reported events under 'Severe harm' or 'Death' outcomes, respectively. Incidents common to most healthcare settings were identified (e.g. medication errors), alongside specialty-specific incidents (e.g. Mental Health Act administration errors). Contributory factors were wide-ranging, with situational failures (e.g. team function failures) and local working conditions (e.g. unmanageable workload) widely reported. Solution categories included service user-directed actions and policy introduction or reinforcement.
conclusionsStudy findings provide novel insights into incidents, contributory factors, and reported solutions within community-based mental healthcare. Targets for safety improvement are outlined, aimed at strengthening system-based prevention of incidents.
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