Table 1 Detailed overview of the main risk themes of clinical risk management in mental health care

A

Clinical risks

General statements about clinical risks without the mention of a specific risk

A1

Clinical risks specific to mental health care

Clinical risks specific to mental health care, i.e. risks that occur only (or predominantly), or are typical, in mental health care

· Admission interview generally considered important

A1.1*

Violence / aggression

General statements about risk themes regarding violence or aggression (physical/psychological). Specific risks are listed in the sub-categories

· Aggression management training

· Violence risk assessment (e.g. Brøset -Checklist)

· Compulsory measures, sensory deprivation, seclusion

· Structural preventive measures

· When too dangerous: prison and external supervision

A1.1.1

Self-destructive behavior

Self-destructive behavior of a patient (e.g. suicide, suicide attempts, self-injury and self-harm: cutting.)

· Good anamnesis, pre-admission interview

· Clarify during admission interview and other consultations

· Intensive support/monitoring

· No-suicide contract

· Closing of the ward

· Good follow-up care and debriefing

A1.1.2*

Compulsory measures

Seclusion, restraint, etc. when mentioned as a risk or as a measure against a risk

· Training

· Standardized procedures

· Inform beforehand

· Observation and/or seclusion room

· Debriefing

A1.1.3*

Next of kin, risks from the outside

Assault/threats from next of kin or from outside

A1.1.4*

Violence with or towards objects

Any form of violence with objects (e.g. weapons, lighters); also violence towards objects (e.g. to destroy furniture)

· No dangerous objects and infrastructure

· Nonflammable material in the rooms

A1.1.5*

Physical vs. verbal abuse

General statements specific to verbal abuse (threats) or physical abuse

A1.2

Treatment errors

Treatment errors / treatment risks during treatment procedure, psychotherapy

· Standard procedures for consultations

· Interdisciplinarity

· Avoid one-to-one consultations

· Anamnesis with pro-active risk assessment

· Sufficient staff

· An ombudsman service that a patient can turn to

A1.2.1

Assaults by staff on patients during the therapeutic process

Assault by a staff member on a patient, especially during the therapeutic setting, that also include, for example, consensual sexual contacts or abuse of power by the therapist

· Special training

· Inform patients specifically about this issue

· Intervision (peer consulting) and supervision

see also A1.2

A1.2.2

Diagnostic errors

Establishing a diagnosis of a mental illness instead of an underlying physical illness or the misdiagnosis of psychiatric illness, which could result in incorrect treatment

· Differential diagnosis

· Additional tools to evaluate physical risks.

A1.2.3

Specific medication risks occurring mainly in psychiatry

All risks related to medication that are (mainly) psychiatric specific, especially: 1) side effects of medication. An important reason why patients do not take their medication. Risk of non-compliance. 2) accumulation, hoarding of medication (e.g. for suicide, substance abuse)

· Clarify patient’s needs

· Information about effects and side-effects

· Information on exercising and nutrition

· Monitor medication intake

A1.3

Risks associated with mental illnesses

Statements about individual illnesses (e.g. addiction, schizophrenia, acute psychosis, mania, depression, anxiety attacks, personality disorder…), that could increase certain risks

· Assessment tools

· Evaluate contractual capacity

· Intensive support

A1.3.1

Hospitalization against the will of the patient

Hospitalization against the will of the patient and/or against the will of next-of-kin. Also lack of insight regarding illness

· Non-voluntary hospitalization, compulsory measures

· Admit voluntary patients only

· Involuntary commitment

A1.3.2

Substance abuse

Drugs, smuggling of substances

· Search patients

· Sign addiction contract

A1.4

Absconding

Patient escapes from psychiatric clinic. This can happen for various reasons, e.g. hears imperative voices, suicidal tendency

· Internal transfer of patient

· Closing of ward

· Search by police

A2

Common clinical risks

Common clinical risks occurring in mental health care, but that are not specific, e.g. medication errors, infections. There are also grey areas such as with falls

A2.1

Medication risks

Common medication risks not specific to mental health care, e.g. confusing medication.

A2.2*

Infections and hygiene

Infections, disease transmission.

· Hygiene, hygiene standards, everything that protects against infection

A2.3

Falls

Falls and their consequences. Likely to be very important with withdrawal symptoms and in geronto-psychiatry

A2.4*

Staff risks

Lack of staff, high workload. Staff absenteeism due to illness (maybe especially high in mental health care?) Shift change, etc. → a latent condition that can increase risk of errors

· Absence management, reintegration, training

· Hire sufficient staff

· Attractive training programs

A2.5

Technology and equipment

Technical equipment used in the treatment of patients

· Control procedures and repair of electronic equipment

· Correct application and periodic maintenance

A2.6

High rate of internal patient transfers

Patient transfers that represent risks at the interface (change of primary caregiver, organization of transfer, etc.)

B*

Other risks (non-clinical)

Common, non-clinical risks (e.g. financial, structural risks, risks relating to image, etc.) e.g. fire, data protection, that represent only an indirect clinical risk

C*

Risks for the staff (Staff safety)

Explicit risks that mainly concern staff members

· Preventive measures (e.g. raising awareness, staff training)

· Active measures (e.g. de-escalation techniques, compulsory measures)

· Follow-up measures (e.g. debriefing, care teams)