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dc.contributor.authorWyder, Marianne
dc.contributor.authorRay, Manaan K
dc.contributor.authorRoennfeldt, Helena
dc.contributor.authorDaly, Michael
dc.contributor.authorCrompton, David
dc.date.accessioned2020-06-11T03:02:54Z
dc.date.available2020-06-11T03:02:54Z
dc.date.issued2020
dc.identifier.issn1353-4505
dc.identifier.doi10.1093/intqhc/mzaa011
dc.identifier.urihttp://hdl.handle.net/10072/394533
dc.description.abstractPURPOSE: To synthesize the literature in relation to findings of system errors through reviews of suicide deaths in the public mental health system. DATA SOURCES: A systematic narrative meta-synthesis using the PRISMA methodology was conducted. STUDY SELECTION: All English language articles published between 2000 and 2017 that reported on system errors identified through reviews of suicide deaths were included. Articles that reported on patient factors, contact with General Practitioners or individual cases were excluded. DATA EXTRACTION: Results were extracted and summarized. An overarching coding framework was developed inductively. This coding framework was reapplied to the full data set. RESULTS OF DATA SYNTHESIS: Fourteen peer reviewed publications were identified. Nine focussed on suicide deaths that occurred in hospital or psychiatric inpatient units. Five studies focussed on suicide deaths while being treated in the community. Vulnerabilities were identified throughout the patient's journey (i.e. point of entry, transitioning between teams, and point of exit with the service) and centred on information gathering (i.e. inadequate and incomplete risk assessments or lack of family involvement) and information flow (i.e. transitions between different teams). Beyond enhancing policy, guidelines, documentation and regular training for frontline staff there were very limited suggestions as to how systems can make it easier for staff to support their patients. CONCLUSIONS: There are currently limited studies that have investigated learnings and recommendations. Identifying critical vulnerabilities in systems and to be proactive about these could be one way to develop a highly reliable mental health care system.
dc.description.peerreviewedYes
dc.languageEnglish
dc.language.isoeng
dc.publisherOxford University Press (OUP)
dc.relation.ispartofjournalInternational Journal for Quality in Health Care
dc.subject.fieldofresearchBiomedical and clinical sciences
dc.subject.fieldofresearchHealth services and systems
dc.subject.fieldofresearchPublic health
dc.subject.fieldofresearchPsychology
dc.subject.fieldofresearchcode32
dc.subject.fieldofresearchcode4203
dc.subject.fieldofresearchcode4206
dc.subject.fieldofresearchcode52
dc.subject.keywordsadverse events
dc.subject.keywordshealth care system
dc.subject.keywordshealth system reform
dc.subject.keywordspatient safety
dc.subject.keywordsquality improvement
dc.titleHow health care systems let our patients down: a systematic review into suicide deaths
dc.typeJournal article
dc.type.descriptionC1 - Articles
dcterms.bibliographicCitationWyder, M; Ray, MK; Roennfeldt, H; Daly, M; Crompton, D, How health care systems let our patients down: a systematic review into suicide deaths, International Journal for Quality in Health Care, 2020
dc.date.updated2020-06-08T01:59:39Z
gro.description.notepublicThis publication has been entered in Griffith Research Online as an advanced online version.
gro.hasfulltextNo Full Text
gro.griffith.authorCrompton, David R.


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