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National Patient Safety Agency

Response from the NPSA to the Healthcare Commission National audit of violence 2006-7

15 February 2008


“The National Patient Safety Agency (NPSA) welcomes this latest report aimed at improving patient safety in the Mental Health Sector. We have long recognised violence in acute psychiatric wards as a key safety issues. We are currently conducting a number of pieces of work to further reduce violent incidents and improve the safety of mental health patients.” Said; Dr Kevin Cleary, Medical Director of the NPSA.


Ward safety audit tool

The National Patient Safety Agency has commenced a stream of work to better understand the factors that underpin patient safety on acute psychiatric wards and how they interact with each other. A review of existing literature relevant to safety on acute wards can be found on the NPSA website. This work has led to the production of a Ward Safety Audit Tool based on the six factors that make up a safer acute psychiatric ward, including the provision of structure, purpose and meaning to the inpatients’ day and the training and development of staff. A download version of the Ward Safety Audit tool will shortly be available from the NPSA website.


Staff training

The National Patient Safety Agency had been working with National Institute for Mental Health in England (NIMHE) on a programme of work including guidance for service providers and on the management of aggression.  It published interim guidance in February 2004 (Developing Positive Practice to Support the Safe and Therapeutic Management of Violence in Mental Inpatient Settings) that covers all ages and has a specific section on age-related issues.


Environment safety

NPSA is working with Department of Health (DH) Estates to review its guidance, for mental health accommodation so that this reflects the most up to date policy.  The provision of a safe, secure, comforting and homely environment is fundamental to the successful delivery of healthcare to patients in acute mental health inpatient settings.


In December 2007 the Missing Patients Toolkit was launched. This resource sponsored by the NPSA and NHS Yorkshire and the Humber SHA is aimed at mental health units, acute and community hospitals. It was developed by trusts in the North and East Yorkshire and Northern Lincolnshire area. The toolkit is intended to help trusts review and improve policy procedure and practice of who could be harmed if they went missing from inpatient care.