Safety investigation – The daily blog of behavioral and cognitive economics

Learning from patient safety incidents

A recent investigation and report by the Health Services Safety Investigations Body has explored how to learn from deaths in mental health inpatient units or when patients die within 30 days of discharge. It found gaps in discharge planning, crisis service accessibility, and access to community therapy that may have contributed to poor outcomes for patients, including deaths. The investigation looked at how mental health inpatient service providers conducted investigations following the deaths of patients and looked at national, regional and local oversight frameworks to examine how providers learn from these deaths. ….[READ]