Safety I and safety II for suicide prevention – lessons from how things go wrong and how things go right in community-based mental health services

Abstract

Prevention of patient suicide is a major challenge for mental health services. This study applied both safety I and safety II approaches to gain an understanding of the detection and response process for suicide prevention in community mental health care in order to compare/contrast outputs from each approach. For safety I, 41 suicide incident reports were analysed using a systemic analysis approach. For safety II, interviews with 20 community-based mental health practitioners and managers were conducted asking their know-hows to successful suicide risk detection and response. The five key issues found from the Safety I approach were: (i) an inherent weakness in the interactions between patient and clinician with the presence of uncertainty in the risk detection; (ii) Poor patients’ engagement with services; (iii) Reliance on patients self-presenting in crisis and declining the offered support options; (iv) Delay in treating new patients; (v) Coordination, communication and process issues. On the other hand, the safety II approach revealed a complex decision-making process with the presence of uncertainty and trade-offs between patient clinical need, patient desire, legal and procedural obligations, and resource considerations. It also revealed a strong theme on the importance of peer-support. The results of this study indicate that safety II approach provides valuable insights into how to strengthen the system performance without challenging systemic issues, while system I approach identifies systemic issues and raise questions how to address them. These findings suggest the potential benefit of applying both approaches to quality and safety improvement in healthcare.