Abstract
Introduction
Patient safety incident reporting has been recognized as a key process for organizational learning and safety culture, but there is limited knowledge about patient safety in forensic psychiatric care.
Aims
To characterize the types and frequencies of incidents in forensic psychiatric care and assess the implications for practice.
Methods
Data were collected from a patient safety incident reporting system (PSiRS) database of one forensic psychiatry hospital in Finland and analyzed using descriptive statistics.
Results
No harm was caused in more than half of the 2,521 reported incidents examined (51%, n=1260). The most frequently recorded incident type was violence (38%), which typically occurred in corridors (31%) or dayrooms (20%). The most frequently recommended action to prevent violent events was that potential risks should be discussed (77%).
Discussion
Patient safety incidents related to violence are common in forensic psychiatric hospitals. Although very few adverse events were classified as causing serious harm to patients, many cases of violence could be prevented by identifying potential circumstances that lead to violence.
Implications for Practice
Staff need encouragement and training to detect and report all patient safety incidents. Safety culture is strengthened by learning and sharing development measures to improve patient safety.