Patient Safety and Mental Health—A Growing Quality Gap in Canada

Abstract

Patient safety research in mental health has focused mainly on suicide and violence risk at the expense of other domains of safety. In Canada, we lack a national strategy or research agenda for this important area. This piece calls on psychiatrists to consider the scope of missed opportunities in patient safety in current practice and presents how to begin to consider the safety of our patients in a systematic manner.

Reviewing the Literature

Patient safety is an essential element of quality health care. Since the publication of the Institute of Medicine's ground breaking report on safety in 1999, health care systems have turned their attention towards the domains of quality and improving patient safety. ¹ In psychiatry, we have a long history of studying and addressing the critical safety issues (i.e., violence, suicide and nonsuicidal self-harm) with more than 7,000 papers published examining suicide in 2020 alone. While these catastrophic outcomes are important and merit our attention, it is increasingly evident that we are failing to study the other common causes of risk and harm to patients and failing to implement the effective strategies we could use to mitigate these risks. ²

Let us look at the literature. In 2020, more than 2,146 papers were published related to patient safety in inpatient care (in all medical specialities), of these only 107 addressed mental health care, and 40% of these were focused on suicide or aggression. Although falls are known to be one of the most common causes of accidents occurring among admitted psychiatric patients, <15 papers looked at falls or falls prevention interventions in inpatient mental health care worldwide. If we fail to study patient safety issues such as falls, medication errors and missed care in mental health settings, we are unable to identify potential areas for improvement and cannot meaningfully implement evidence-based programs to reduce harm.

As our colleagues in medicine and surgery have made strides in safer care (i.e., reducing line infections and increasing guideline adherent care), ³ we have been largely left behind. The majority of large-scale published quality and safety studies exclude mental health settings precluding the comparison of the risks of mental health care to general medical care and preventing the rapid adoption of learning arising from these large institutional studies. ³ Voluntary incident reporting systems are widely used in health care settings to track adverse events and near misses and inform future improvement interventions. These methods are thought to capture <25% of incidents occurring in most settings. ⁴ To address this deficit, a trigger tool is often used to improve incident detection. But trigger tool methodology, one of the gold-standard methods used to track patient risk in inpatient settings, excludes psychiatric settings meaning mental health programs must rely on voluntary reporting, with all its inherent weaknesses. ⁵ As a result, we do not routinely capture and report on common safety risks in mental health units with the same level of rigor as the rest of our medical colleagues. This excludes mental health practitioners from the process of learning about and improving their practices alongside our colleagues, missing opportunities for systems learning and collaboration.

Adverse Events in Mental Health

This lack of attention is not because our patients are not at risk. Mental health patients have the same, if not higher, risk of adverse events occurring during care as medical or surgical patients. In England, for example, incidents leading to death in patients receiving mental health care represent 57% of these deaths in the whole health care system. ⁶ At least 10% of all patients admitted to a hospital experience an adverse event ⁴ —in Canada, with 227,946 admissions to psychiatric care each year, we could reasonably estimate that more than 22,000 patients experience an adverse event, or 62 patients each day. ⁷ The numbers for mental health ambulatory services in Canada are unknown, however, the literature suggests medication errors are most common with little or no harm arising. ⁸ There is little published on the more likely causes of risk to our outpatients—lack of timely care or missed diagnoses (i.e., the failure to identify a medical or psychiatric comorbidity). ⁹ These systemic barriers and biases lead to great accrual of risk to our patients, all of which remains largely unmeasured and unaddressed.

We need to reflect on our practices in mental health—what are we doing that may be amplifying this increasing gap in patient safety? In the literature, we have, as a speciality, largely defined safety as the reduction of suicide and acts of violence. ¹⁰ These issues are important, and the outcomes are severe, however, they are relatively rare, and we are failing to study the full breadth of risks that face our patients while receiving care. While under our care, patients are more likely to be misdiagnosed, receive the wrong medication or fail to receive their planned treatment in a timely manner than they are to die by suicide or be subject to violence. ¹¹ A Delphi study undertaken in Switzerland to determine priorities for patient safety in mental health identified diagnostic and structural errors as the highest priority to address. ⁹ Misdiagnosis (including the misidentification of medical conditions as mental illness and vice versa) and missed diagnosis (including failure to identify comorbid psychiatric conditions or medical conditions) were identified as causing significant risk and harm over time to patients and in need of greater study. Structural errors, also known as latent errors, similarly lead to the accrual of harm over time. These errors arise as a result of policy or funding decisions that lead to limited access to indicated care or the provision of care that is substandard in some way. Given the widespread concern about access and underfunding in mental health in Canada, it is hard to imagine these errors are not contributing to harm Canadian patients.

Psychological Harm From Care

In mental health, we also struggle with acknowledging, let alone measuring, the psychological harm caused by care. “Medical PTSD” is increasingly recognized in the lay press and by medical organizations. ¹² The receipt of health care can be traumatic for some patients—this is especially true in acute psychiatric services. ¹³ Trauma and avoidance can lead to disengagement in treatment and lack of access to needed treatments. According to CIHI, 24% of all individuals admitted to a designated mental health bed in Ontario received at least one “control intervention” during their admission including acute control medication, mechanical or physical restraints or seclusion. ¹⁴ Not only are the patients subject to the control interventions affected but also there is an impact on the other patients who witness the event and may experience fear or decreased sense of safety in their care environment. ¹⁵ Further patient safety work should consider the impact of stigmatization on safe care. ¹⁶ As a result of stigma, patients with mental health diagnoses are more likely to be dismissed when receiving health care, patients may hesitate to fill needed prescriptions due to fears of judgement and patients may be reluctant to attend services at settings widely identified as mental health service providers. As we move forward in addressing the patient safety gap in mental health, we must include patients and families in our work and actively address psychological harm and stigma in the interventions to have a meaningful impact on safety.

The Canadian Context

Canada specifically has fallen critically behind in patient safety in mental health. Since the publication of the comprehensive review “Patient Safety in Mental Health” ¹⁷ in 2009 calling for a national standardized patient safety framework specific to mental health, there is little evidence of progress made in key recommendations neither in the published literature nor in reviewing relevant websites such as Healthcare Excellence Canada (formerly the Canadian Patient Safety Institute), the Mental Health Commission of Canada and the Canadian Institute for Health Information. Certainly, the systemic biases outlined above are contributing to this, however, we are also lagging behind our mental health colleagues in other jurisdictions. In the United Kingdom, the National Reporting and Learning System (previously the National Patient Safety Agency) ¹⁸ is a voluntary reporting framework implemented nationwide in all health care settings. It is nuanced and allows one organization to focus on different outcomes from another and has a range of outcomes and indicators for quality mental health care along with physical health care. Each organization receives regular reports on their performance and can make inquiries for data related to areas of interest. In Switzerland, following up on the results of their Delphi study, ⁹ a national action plan for patient safety in mental health was developed. ¹⁶ International research priorities for patient safety in mental health were developed via expert interviews and Delphi in 2018, notably, there were no participants from Canada in the process. ¹⁰

The structure of health care delivery in Canada aggravates this situation. While quality health care delivery is widely recognized as a national priority, funding and administration are at the province and territorial levels. Privacy and personal health information legislation varies by jurisdiction as do Mental Health Acts and restraints legislation leading to differing practices between regions and limiting the ease of simple data sharing. It is possible there is robust mental health patient safety work going on across Canada, each centre working in isolation. The concern remains that we are not sharing our work and learning from each other. Overcoming our geographical and jurisdictional limitations will require leadership from a national organization such as the Canadian Psychiatric Association.

Moving Forward

In mental health patient safety, we do not know what we are missing—what incidents are occurring, how often and what effective interventions may already exist to keep our patients safer. How can we start to change this? At this point, one might be thinking that these common causes of harm are not important issues in their setting. This is not surprising; we often conflate importance with attention. These issues receive little attention in our day-to-day work or in our literature. Chances are many of us have not seen any kind of report or update outlining these safety issues and most of us have not seen rounds or publications talking about these risks. If one was curious, they could ask the chief or manager about incident reporting in their setting and look at a quarterly report for the inpatient unit or outpatient service. When we learn what is routinely measured then we can ask is it what should be measured? Is it important? One should pay attention to new patient safety initiatives in their institution and ask why psychiatry is not included—advocate for our patients to have access to these important innovations. To build capacity and competence in patient safety, attend incident debriefs and participate in morbidity and mortality rounds and consider obtaining additional training in quality improvement and patient safety.

But we need more than individual action. In Canada, psychiatry is falling critically behind in patient safety. We lack a national strategy, an agreed-upon set of key safety indicators or a critical mass of collaborative patient safety research and innovation that could lead to system-wide changes. ¹⁷ We are not alone; others have struggled similarly and recently, and we can learn from them. In Switzerland, they have developed an action plan outlining the next steps in addressing this relatively neglected area of study. ¹⁶ In the United Kingdom, they undertook a systematic review studying patient safety in inpatient mental health settings ¹⁹ and using the Delphi method identified research priorities for patient safety in mental health. ¹⁰ It has been more than 10 years since our own national report on patient safety in mental health was published calling for action at the national level including the development of a national framework for action or patient safety strategy. ¹⁷ There has been no discernible action. It is time to act; our patients need us. To do this, we need leadership from our national organizations, administrative support for collaboration across provincial and territorial boundaries and funding for research in the full scope of patient safety in mental health. This paper is a nudge, to all of us, to start down the road to safer care and to begin the dialogue needed to achieve system-level improvement.