• Led by Hertfordshire Partnership NHS Foundation Trust.
  • Focused on acute mental health care and dementia care pathways across the Eastern region’s five mental health trusts.
  • Aimed to improve patient safety in mental health care by addressing teamwork and communication issues that can affect the safety and effectiveness of care, and patient experience.
  • Delivered two key patient safety interventions – system safety assessment training and human factors training.

Recognised patient safety risks in mental health care include suicide and serious harm within adult mental health care pathways, and falls, violence and aggression within dementia care pathways.

This project aimed to address these risks through an integrated patient safety programme in five project sites in Hertfordshire, and across adult and older people’s mental health care pathways. It was led by Hertfordshire Partnership NHS Foundation Trust, with partners including the University of Hertfordshire, the University of Cambridge Engineering Design Centre’s Healthcare Design Group and the University of East Anglia.

Clinical teams were trained in system safety assessment (SSA) and human factors (HF). SSA is a rigorous process of analysing and prioritising action on future risks. HF training enables a shift in staff culture to being more proactive and collaborative on patient safety. This project was unique in combining SSA and HF training in the mental health setting.

One of the key lessons from the project was that these two training elements go hand in hand, and that patient safety improvement is much stronger if they are used in combination.

Evaluation of the project was carried out by a team at the University of Cambridge. It included data collection, self-assessment of patient safety within the trusts, assessment of patient safety culture before and after the project, an analysis of attitudes towards training activities, and evaluation of the impact of the project on patient safety.

The evaluation showed that the intervention was effective in supporting the sites to make positive changes to clinical practice. Significant safety culture improvements were found in six out of 12 domains, using an established patient safety culture measure. Training was positively received and there were indications of behavioural change in teams across the project sites.

Where data are available, the patient safety improvement projects initiated were associated with moderate decreases in patient safety incidents.

Although teams maintained enthusiasm throughout, there were barriers to maintaining momentum, including organisational and personnel changes, and CQC inspections. Flexibility throughout the project was vital to overcoming these challenges.

Involving service users and carers throughout had a significant impact. However, a key learning point was that they need sessions tailored to their needs.

An online version of the SSA tool has been developed, which will enable continued use and spread. Work on cascading use of the tools within care pathways and the wider organisations is underway.

Contact details

For further information about the project, please email Tim Bryson.

About this programme


Closing the Gap in Patient Safety


This programme ran from 2014 to 2017, and offered funding for projects to implement and evaluate...

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