Improving safety in mental health

Like all other care sectors, mental health has its share of harmful events which could, or should, have been avoided.

Everyone involved in providing mental health services can help to reduce harm and improve patient safety. The vulnerable nature of many service users means mental health staff can play a particularly active and important role in safeguarding and improving safety.

The Safer Care team is dedicated to building an NHS where every member of staff has the passion, confidence and skills to eliminate harm to patients. We work with NHS Trusts in all sectors – including mental health – to help them build their capacity and capability for quality and safety improvement.

The Leading Improvement in Patient Safety (LIPS) programme for mental health

In partnership with mental health professionals, we have developed a version of the LIPS programme for mental health. It has the same aims and outcomes as the acclaimed acute LIPS programme but has been designed to meet the specific needs of the mental health sector. It includes specific examples drawn for clinical practice in mental health, together with tailored measurement tools.

As there are relatively few mental health NHS Trusts, delivering this programme to groups of trusts on a regional basis would produce shared learning and greater cost effectiveness.

Who is Mental Health LIPS for?

The programme is geared to safety improvement at all levels within organisations. It is aimed at senior medical and nursing staff, including directors, chief executives and their board-level colleagues and patient safety leaders. Effective leadership and championing of safety improvement from the most senior levels in the organisation is crucial for effective improvement projects to work. This is why we make securing that level of involvement in the LIPS programme a condition of participation.

What does the programme involve?

The programme is delivered in three modules over a total of seven days. A mix of teaching, group discussions, reflection and practical exercises is led by experts from the NHS Institute.

The programme elements are:

Module one - Getting Started (two days)
  • Understanding the causes of harm to patients
  • How to use targeted case note review to measure your harm rate
  • Understanding why we reliably fail
  • Human factors in patient safety
  • Using driver diagrams to plan an improvement project
  • The Model for Improvement and small scale tests of change
  • Measurement for improvement
  • Improving culture, teamwork and communication

Module two - Executive Quality and Safety Academy (EQSA) - running concurrently with Getting Started: (two days)

Designed to increase your executive team capacity to lead organisational improvement. Leave with a detailed plan to improve safety in your trust. Webinar to review progress and submit aims

Module three - Core Module (three days)

  • Understand more about reliability; human factors, driver diagrams and how they apply to improvement within patient safety issues in mental health.
  • An opportunity to present learning and outcomes to your Chief Executives

Targeted Case Note Review

A tool has been developed to measure rates of patient harm in mental health. A development group, which included senior staff from NHS Mental Health Trusts, worked with us to develop this tool. It produces an accurate measure of harm identified from case notes and provides opportunities to learn from such events. The tool is specific to mental health settings and does not rely on reporting culture. Once improvement initiatives are put in place, the tool allows organisations to track progress over time.

In order to use find out more and use the targeted case note review tool and its associated portal, you will need to register to use the Trigger Tools portal. Click here to complete registration.

For more information about the LIPS programme for mental health – including pricing and how to apply – please email: