Objective: Risk management in mental health focuses on risks in patients and fails to predict rare but catastrophic events such as suicide. Commercial aviation has a similar task in preventing rare but catastrophic accidents. This article describes the systems in place in commercial aviation that allows that industry to prevent disasters and contrasts this with the situation in mental health.
Conclusions: In mental health we should learn from commercial aviation by having: national policies to promote patient safety; a national body responsible for implementing this policy which maintains a database of safety occurrences, sets targets and investigates adverse outcomes; legislation in place which encourages clinicians to report safety occurrences; and a common method and language for investigating safety occurrences.
ApplebyLShawJAmosT. Suicide within 12 months of contact with mental health services: national clinical survey. British Medical Journal1999; 318: 1235–1239–
