National safety priorities in mental health: a national plan for reducing harm

Appendix 11 - Selected resources for further reading

Page last updated: October 2005

Following are some selected resources relevant to safety and quality issues in mental health. Preference has been provided to accessible resources relevant to the priorities identified in this Plan. The lists are by no means exhaustive.

Website links and phone lines were accurate at the time of printing. Responsibility for the content of the listed resources rests with the respective authors.

Safety and quality in general
Clinical resources
Suicide prevention
Seclusion and restraint
Adverse drug events
Medicines phone help lines
Safe transport

Safety and quality in general

Australasian Cochrane Centre website

Australian Council for Safety and Quality in Health Care website

Australian Council on Healthcare Standards website

Australian Patient Safety Foundation website

Australian Resource Centre for Healthcare Innovations (ARCHI) website

Doing Less Harm: Improving the safety and quality of care through reporting, analysing and learning from adverse incidents involving NHS patients - Key requirements for health care providers (UK publication).

Guidelines for Determining Benefits for Health Insurance Purposes for Private Patient Hospital-Based Mental Health Care.

Institute for Health Care Improvement.Top of page

International Society for Quality in Health Care Inc.

Joint Commission on Accreditation of Healthcare Organizations, USA.

Key Performance Indicators for Australian Public Mental Health Services. PDF available on the Department of Health website

Australian Mental Health Outcomes and Classification Network (AMHOCN) website

National Centre for Patient Safety, US National Veterans Administration Health website. Includes the Safety Assessment Code (SAC) matrix page (www.patientsafety.gov/matrix.html)

National Mental Health Strategy publications

National Practice Standards for the Mental Health Workforce. PDF available on the Department of Health website Top of page

National Standards for Mental Health Services. PDF available on the Department of Health website

National Triage Scale, ACEM.

Quality Improvement Council website

Report on Incident Management in the NSW Public Health System 2003-2004. PDF available on the NSW Ministry of health website

Safer Health Care (International site).

To Err is Human: Building a Safer Health System. Available on the National Academies Press website

UK National Institute of Clinical Excellence (NICE) website

United Nations Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care. Available on the United Nations website

Victorian Department of Human Services, Clinical Risk Management

Victorian Department of Human Services, Sentinel Event Annual Report.

Victorian Department of Human Services - Strategy for safety and quality in public mental health services. PDF available on the Victorian Department of Health website

Victorian Quality Council publications page Top of page

WA Office of Safety and Quality in Health Care (OSQH) website

WA Office of Safety and Quality in Health Care publications include:
Clinical Risk Management
  • Clinical Risk Management Guidelines for the WA Health System
  • Pocket Guide to Clinical Risk Management
  • Desktop Guide to Clinical Risk Management
Complaints Management
  • Premier's Circular 2004/04 - Whole of Government Complaint Management Strategy
  • Department of Health (2005). Complaint Management at the Department of Health
  • Department of Health (2005). Complaint Process Flow Chart
  • Department of Health (2003). Western Australian Complaints Management Policy: Driving Quality Improvement by Effective Complaints Management
  • Metropolitan Hospital and Health Service Annual Complaints Report 2002 – 2003
  • Metropolitan Hospital and Health Service Annual Complaints Report 2003-2004
  • WA Country Health Service Annual Complaints Report 2003-2004
  • Department of Health Annual Complaint Report 2003-2004
  • Informed Consent
  • Procedure Specific Consent Forms
  • Guidelines for Health Practitioners: Patient Consent to Treatment and Disclosure of Material Risks (Oct 2000)
  • Questions to Ask Your Doctor About Proposed Tests, Treatment or Procedures (See Appendix A) Top of page
Credentialing
  • Credentialing an Introduction
Incident Reporting and Management
  • Incident Reporting and Management Policy
Sentinel Events
  • Statewide Sentinel Events Reporting Policy
  • Sentinel Event Report Form
  • Clinical Incident and Root Cause Analysis (RCA) Forms
Qualified Privilege
  • Qualified Privilege Guidelines
WHO World Alliance for Patient Safety website Top of page

Clinical resources

Australasian College for Emergency Medicine and Royal Australian and New Zealand College of Psychiatrists (2000) Guidelines for the Management of Deliberate Self Harm in Young People. PDF available on the Australasian College for Emergency Medicine website

Boyce P, Carter G, Penrose-Wall J, Wilhelm K and Goldney R (2003) Summary Australian and New Zealand clinical practice guideline for the management of adult deliberate self-harm (2003),
Australasian Psychiatry, Volume 11, No. 2, June 2003

Clinical Governance, Western Australia

Documents on this site include:
  • Introduction to Clinical Governance: A Background paper
  • Clinical Governance: Reference by Topics
  • Clinical Governance: A Framework of Assurance and Review for Clinical Responsibility and Accountability in Western Australian Health Services
  • Clinical Governance Framework
  • Western Australian Clinical Governance Guidelines
  • Setting Standards for Making Health Care Better: Implementing Clinical Governance in WA Health Services
  • Clinical Governance Standard
Western Australian Clinical Governance Guidelines. PDF available the Office of Safety and Quality in Healthcare website

National Institute of Clinical Studies as of 1 April was incorporated into the National Health and Medical Research Council

National Institute for Health and Clinical Excellence - UK website

Royal Australian and New Zealand College of Psychiatrists (RANZCP), Clinical Practice Guidelines page on RANZCP website

Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care, CG16 Self-harm - NICE guideline

Standards in Care Outcomes in Licensed Psychiatric Hostel for People with a Psychiatric Disability, Office of the Chief Psychiatrist (OCP) Western Australia, May 2003. Available on the OCP website

Victorian Department of Human Services, Chief Psychiatrist's Guidelines page on the Victorian Department of Health website

Violence - The short-term management of disturbed/ violent behaviour in in-patient psychiatric settings and emergency departments, CG25 Violence - NICE guideline - 2005

WA Centre for Clinical Interventions (CCI) website

WA Framework for Clinical Risk Assessment and Management of Harm Available on the WA Health website Top of page

Suicide prevention

Auseinet - Australian Network for Promotion, Prevention & Early Intervention for Mental Health website

Boyce P, Carter G, Penrose-Wall J, Wilhelm K and Goldney R (2003) Summary Australian and New Zealand clinical practice guideline for the management of adult deliberate self-harm (2003), Australasian Psychiatry, Volume 11, No. 2, June 2003

Community Life-Building Community Capacity for Suicide Prevention

National Suicide Prevention Strategy. PDF available on the Department of Health website

NSW Mental Health Sentinel Events Review Committee, Tracking Tragedy: A systemic look at suicides and homicides amongst mental health patients, First Report of the Committee, December 2003. PDF available on the NSW Ministry of Health website

NSW Government Response to the Tracking Tragedy Report. PDF available on the NSW Ministry of Health website

NSW Mental Health Sentinel Events Review Committee Tracking Tragedy 2004: A systemic look at homicide by mental health patients and suicide death of patients recently discharged from mental health inpatient units, Second Report of the Committee, March 2005. PDF available on the NSW Ministry of Health website

Rebecca Slinn, Amanda King, Jonathon Evans A national survey of the hospital services for the management of adult deliberate self-harm, Psychiatric Bulletin (2001) 25, 53-55.

Royal College of Psychiatrists, London The General Hospital Management of Adult Deliberate Self-Harm: A Consensus Statement on Standards for Service Provision Council Report, CR32 June 1994. PDF available on the Royal College of Psychiatrists website

Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care, CG16 Self-harm - NICE guideline. PDF available on the National Institute for Health and Clinical Excellence website

WA Framework for Clinical Risk Assessment and Management of Harm. Available on the WA Health website Top of page

Seclusion and restraint

American Nursing Association Reduction of Patient Restraint and Seclusion in Health Care Settings: Position Statement, October 17, 2001.

American Psychiatric Association American Psychiatric Nurses Association, National Association of Psychiatric Health Systems. Learning from Each Other, Success Stories and Ideas for Reducing Restraint/ Seclusion in Behavioural Health, (2003).

American Hospital Association Guiding Principles on Restraint and Seclusion for Behavioral Health Services, 1999. Available on the National Association of Psychiatric Health Systems

Bluebird, G (2004) Redefining Consumer Roles: Changing Culture and Practice in Mental Health Care Settings, Journal of psychosocial nursing, Vol. 42, No.9, September 2004, pp46-53.

Bower F L, McCullough C S and Timmons M E (2003) 'A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update', The Online Journal of Knowledge Synthesis for Nursing, Vol. 10, Document No. 1

Broadstock M The Efffectiveness and Safety of Drug Treatment for Urgent Sedation in Psychiatric Emergencies: A critical appraisal of the literature. NZHTA Report 2001. PDF available on the University of Otago website

Cannon M E, Sprivulis P, and McCarthy J (2001) Restraint practices in Australasian emergency departments, Australian and New Zealand Journal of Psychiatry, 2001; 35:464-467.

Champagne T & Stromberg N, Sensory Approaches in Inpatient Psychiatric Settings: Innovative Alternatives to Seclusion and Restraint, Journal of psychosocial nursing, Vol. 42, No.9, September 2004, pp35-44.

Day, P What evidence exists about the safety of physical restraint when used by law enforcement and medical staff to control individuals with acute behavioural disturbance? New Zealand Health Technology Assessment (NZHTA) September 2002 Volume 1 Number 3. PDF available on the University of Otago website

Emergency Demand Policy - P6-02, Restraint and Seclusion in Health Units (Including Mental Health Situations), South Australian Department of Human Services 2002. Accessed via the SA Health website

Huckshorn KA, Reducing Seclusion and Restraint Use in Mental Health Settings: Core Strategies for Prevention, Journal of psychosocial nursing, Vol. 42, No.9, September 2004, pp22-33.

Joint Commission on Accreditation of Healthcare Organisations USA, American Sentinel Event Alert Preventing Restraint Deaths, Issue 8, November 18, 1998.

Michael S Pollanen, PhD; David A. Chiasson, MD, Unexpected death related to restraint for excited delirium: a retrospective study of deaths in policy custody and in the community, Canadian Medical Association Journal 158:1603-7, 1998. Available on the National Center for Biotechnology Information website Top of page

National Alliance on Mental Illness (NAMI) Policy Research Institute, Seclusion and Restraints Task Force Report, May 2003. PDF available on the National Alliance on Mental Illness website

Nurses Board of Western Australia, Guidelines for the use of restraint in Western Australia, August 2002.

Nursing Board of Tasmania Standards for the use of restraint as a nursing intervention (website no longer exists)

Sailas E, Fenton M Seclusion and restraint for people with serious mental illnesses, The Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.: CD001163. DOI: 10.1002/14651858.CD001163.

Standards (includes standards related to use of restraint and seclusion). Available on the Joint Commission website

US Health Care Financing Administration rules on seclusion and restraint. July 11, 1999

US National Association of State Mental Health Program Directors Position statement on seclusion and restraint, (1999). PDF available on the NASMHPD website

US National Association of State Mental Health Program Directors Position statement on services and supports to trauma survivors, (2005).

Victorian Department of Human Services Chief Psychiatrist's Guidelines - Seclusion.

Victorian Department of Human Services Chief Psychiatrist's Guidelines - Mechanical Restraint.. PDF available on the Victorian Department of Health website

WA Mental Health Act (1996) Conditions under which seclusion is undertaken in Western Australia.

WA Mental Health Act (1996): Regulations on the authorisation, observation and recording of seclusion in Western Australia.

Wanda K Mohr, Phd, Rn, FAAN, Theodore A Petti, MD, MPH, Brian D Mohr, MD, Review Paper: Adverse Effects Associated with Physical Restraint, The Canadian Journal of Psychiatry, June 2003. Top of page

Adverse drug events

ADRAC's, Australian Adverse Drug Reaction Bulletin. In 2010, ADRAC was replaced by the Advisory Committee on the Safety of Medicines (ACSOM)

Australian Prescriber newsletter website

Better Health Channel, Consumer Medicines Guide page available on the Better Health Channel

Clinical guidance on the use of antidepressant medication in children and adolescents. Joint statement about use of SSRIs in the treatment of psychiatric and developmental disorders in children and adolescents. Available on the RANZCP website

Consumer Medicine Information (CMI).

What is CMI? (brochure)

CMI (poster).

Grasso B C, Rothschild J M, Genest R, Bates D W (2003) 'What do we know about medication errors in inpatient psychiatry?', Joint Commission Journal on Quality and Safety, Vol. 29, No 8, August 2003.

HealthConnect

MedicinesTalk - produced by consumers, for consumers to encourage and promote Quality Use of Medicines (QUM). Available on the NPS Medicine Wise website

Medication Safety Breakthrough Collaborative

MedWatch: The United States Food and Drug Safety Information and Adverse Event Reporting Program page

Medimate

Brochure on Medimate. PDF available on the NPS Medicine Wise website

MIMS website

National Association of State Mental Health Program Directors, NASMHPD Medical Directors' Technical Report on Psychiatric Polypharmacy, NASMHPD, September 2001. Top of page

National Medicines Policy, Policy on Quality Use of Medicines

National Prescribing Service Medicine Wise website

National Prescribing Service - Radar (Rational Assessment of Drugs & Research) page on the National Prescribing Service Medicine Wise website

Quality Use of Medicines (QUM) Map website

RANZCP Position Statement on the Safe Use of Clozapine. Available in the EPA Handbook on the RANZCP website

Victorian Mental Health Branch of the Department of Human Services. Brochures on psychotropic medication.

Western Australian Medication Notifications

Western Australian Medication Review

Western Australian Psychotropic Drug Committee (WAPDC) website

Guidelines and Information available on the above site:
Antidepressants (January 2005)
Antidepressants - Therapeutic algorithm Part 1
Antidepressants - Therapeutic algorithm Part 2
Includes sections on:
  • Guidelines for the drug treatment of depression
  • Algorithm for pharmacotherapy of depression
  • Clinical conditions influencing selection of antidepressants
  • Switching antidepressant agents
  • Adverse effects that influence selection of antidepressants
  • Clinically relevant drug interactions with newer antidepressants
  • Printed copies are also available by contacting WATAG.
Antipsychotic Drug Guidelines (July 2003)
Includes Therapeutic Algorithms for:
  • Early Episodes Top of page
  • Relapse and Exacerbation
  • Acute Arousal
  • Antipsychotic Induced Cardiac Arrhythmia
  • Key Points for Antipsychotic therapy in clinical practice
Other Information
  • Guidelines for the use of psychotropic drugs
  • Prescription and supply of risperidone long acting depot injection
  • Risk of hyperglycaemia and diabetes mellitus associated with use of antipsychotic drugs
  • Use of SSRI and SNRI antidepressants in children and adolescents
Advisory Notes
  • Caution required with olanzapine intramuscular
  • Olanzapine intramuscular injection
  • New Anticonvulsants as Mood Stabilisers
  • Metabolic disturbances with antipsychotics
  • Lithium revisited - frequently asked questions
  • Clozapine & gastrointestinal adverse effects
  • Atomoxetine - how useful for ADHD?
  • Clozapine augmentation
  • Aripiprazole - a new class of antipsychotic
  • Lithium induced hypothyroidism. When to treat
  • Risperdal Consta
  • Combining antidepressants
  • Reboxetine - a'NaRI'
  • Profile of amisulpride

Medicines phone help lines

National Prescribing Service: Consumer Adverse Medication Events Line: Ph 1300 134 237 Top of page

Safe transport

Emergency Demand Policy P7-02 Emergency Transport of Mental Health Consumers from Country Locations, South Australian Department of Human Services 2002. PDF available on the SA Health website

Police Protocol between the Western Australian Police Service and Mental Health Services of the Health Department of Western Australia. PDF available on the Office of the Chief Psychiatrist (OCP) website

Towards a national approach to information sharing in mental health crisis situations (2000).

Victorian Department of Human Services, Protocol between Victorian Police and the Department of Human Services Mental Health Branch July 2004. PDF available on the Victorian Department of Health website

Victorian Department of Human Services, Ambulance transport of people with a mental illness, (2002). PDF available on the Victorian Department of Health website