Quality improvement module 4: Patient safety in mental health

by Rachel Grace Paskell


Last reviewed: May 2018


Patient safety should be at the forefront of everything we do when we deliver any care or treatment:


‘First do no harm.’


Since the 1990s the patient safety movement has grown and gained momentum and there has been a move away from a culture of blame and towards an approach that promotes openness and learning from errors.


Ensuring that patients are safe involves risk assessment, the identification and management of patient-related risk, and the reporting and analysis of incidents. It also requires the capacity to learn from and follow up on incidents, and to implement solutions to minimise the risk of them reoccurring.


This module summarises key topics from the literature, provides definitions of patient safety and harm, and looks at some of the lessons that should be learned from recent failures in healthcare. These include findings relating to the Mid Staffordshire NHS Foundation Trust and to Winterbourne View hospital. Various models of patient safety are outlined, including the linear ‘Swiss cheese’ model and various non-linear models.


A key theme is the value of reporting, investigating and learning from incidents. This module looks at guidelines, initiatives and tools for ensuring that this happens both locally and nationally to prevent further harm. It also identifies the most commonly reported types of incident within mental healthcare and highlights particularly relevant ‘Never Events’, i.e. types of serious incident that are wholly preventable if recommendations made at a national level have been implemented.


Start the module


College Centre for Quality Improvement

Other modules in this series:


Clinical audit in mental health practice by Robin Burgess


QI essentials by Dr Genevieve Holt and Dr Amar Shah


Organisation theory: conceptual frameworks in a changing context by Professor David Crowther and Dr Miriam Green


History of quality of healthcare in the UK by Dr Charles Shaw and Adrian Worrall


BJPysch Advances: related articles for CPD Online



Related Advances articles


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This is the fourth in a series of modules developed in association with the College Centre for Quality Improvement (CCQI).


© 2021 Royal College of Psychiatrists