"The Process Is Built for Psychological Safety": Behavioral Health Providers' Experiences Using a Systems-Based...

Learning from critical incidents is a major component of efforts to improve patient safety that increasingly center on system-level factors rather than individual errors to both address root causes of critical incidents and promote psychological safety in health care and social service agency cultures. However, there are limited studies of professionals' experiences with system-level critical incident review processes and how these experiences influence practice in behavioral health settings.

This mixed-methods study explores how practitioners at the largest behavioral health agency in California perceived the use of the Safe Systems Improvement Tool to learn from critical incidents, including deaths by suicide, overdoses, and near misses.

Survey and interview data from behavioral health practitioners indicated that for critical incident reviews, empathetic facilitation, deliberate preparation, and expectation-setting before meetings support psychological safety and systems change. Participants recommended including front-line as well as clinical and supervisory staff in critical incident reviews and developing clear timelines for implementing follow-up recommendations.

The application of critical incident reviews in behavior health agencies can be effective not only in identifying root causes and quality improvement opportunities through the aggregation of data across events, but also in fostering cultures of psychological safety to reduce individual blame and defensiveness while promoting transparent system-wide assessment and transformation.