Table 1.

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

Risks	Main- / subcategories	Risk description	Number spont.	Number total	Total spont.	Total overall	Mentioned organizational CRM practices (selection)
A	Clinical risks	General statements about clinical risks without the mention of a specific risk	1 of 11	1 of 11	1	2
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	1 of 11	3 of 11	1	5	· 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	8 of 11	10 of 11	12	42	· 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.)	9 of 11	11 of 11	11	51	· 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	4 of 11	9 of 11	4	31	· 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	1 of 11	2 of 11	1	4
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)	0	2 of 11	0	5	· 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	0	2 of 11	0	3
A1.2	Treatment errors	Treatment errors / treatment risks during treatment procedure, psychotherapy	4 of 11	11 of 11	6	33	· 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	2 of 11	3 of 11	2	6	· 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	1 of 11	2 of 11	2	3	· 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)	1 of 11	4 of 11	1	7	· 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	4 of 11	10 of 11	6	21	· 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	3 of 11	8 of 11	3	12	· Non-voluntary hospitalization, compulsory measures
							· Admit voluntary patients only
							· Involuntary commitment
A1.3.2	Substance abuse	Drugs, smuggling of substances	1 of 11	4 of 11	1	4	· 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	3 of 11	6 of 11	4	9	· 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.	5 of 11	9 of 11	7	33
A2.2*	Infections and hygiene	Infections, disease transmission.	5 of 11	7 of 11	5	26	· 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	1 of 11	5 of 11	1	12
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	1 of 11	9 of 11	2	28	· Absence management, reintegration, training
							· Hire sufficient staff
							· Attractive training programs
A2.5	Technology and equipment	Technical equipment used in the treatment of patients	2 of 11	3 of 11	2	4	· 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.)	0	2 of 11	0	3
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	6 of 11	11 of 11	14	47
C*	Risks for the staff (Staff safety)	Explicit risks that mainly concern staff members	1 of 11	11 of 11	2	38	· 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)

Description of the individual columns in Table 1:

· Risks: numbering of risk categories and sub categories (A > A1 > A1.1 etc.).

· Main category / sub category: names of the risk categories.

· Risk description: explanation of the meaning of the mentioned risk.

· Number of spontaneously mentioned risks: shows in how many of the 11 interviews the corresponding risk was spontaneously mentioned at the beginning of the interview.

· Total number: shows in how many of the 11 interviews the corresponding risk was mentioned during the interview.

· Total number of spontaneously mentioned risks: shows how often the corresponding risk was spontaneously mentioned in total at the beginning of all 11 interviews (multiple mentions in the same interview are included).

· Overall total of mentioned risks: shows how often the corresponding risk was mentioned in total during all 11 interviews (multiple mentions in the same interview are included).

· Mentioned CRM practices (selection): selection of possible measures on how to deal with the corresponding risk mentioned during the interviews.

The most important risks mentioned in more than half of the interviews or more than 20 times in total are italicized.

* Marked with an asterisk are those risks that are important to patient as well as to staff safety.