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Related Concept Videos

SBAR II: Application of SBAR01:14

SBAR II: Application of SBAR

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SBAR is an effective communication tool used by healthcare professionals to communicate patient information accurately. SBAR stands for Situation, Background, Assessment, and Recommendation. For a better understanding, an example is given below.
SBAR Report from a Nurse to a Health Care Provider
S: "Hello, Dr. Smith. This is Jane, RN, from the Med Surg unit. I am calling to tell you about Ms. White in Room 210, who is experiencing increased pain and redness at her incision site. Her recent...
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Nursing Clinical Information System01:27

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Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
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Types of Reports II: Incident or Occurrence Report01:21

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An Incident or Occurrence Report in a healthcare setting is a crucial document used to record any unexpected occurrence that may or may not have affected a patient, employee, or visitor. Such reports are critical to improving patient safety and include all details leading up to and including the event.
Purposes:
In the healthcare industry, reports play a crucial role in documenting incidents within an agency. The primary objective of these reports is to ensure patient safety, uphold the...
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Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
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SBAR I: Understanding the Concept01:29

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Effective communication among healthcare professionals during hand-off reporting is essential to delivering safe and continuous patient care. Common professional interactions include reports to healthcare team members, hand-off, and transfer reports. Nurses routinely report information to other healthcare team members and also urgently contact healthcare providers to report changes in patient status.
Standardized methods of communication have been developed to ensure that information is...
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An integrated healthcare system (IHS) is a set of organizations that provides for or arranges to provide coordinated and continuous service to a defined population. The IHS takes responsibility for that particular population's health status and outcome, both clinically and fiscally. An integrated healthcare system is a well-organized, well-coordinated, and collaborative network. The integrated delivery system is a network that connects different healthcare providers to deliver organized,...
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Implementation of a Real-Time Psychosis Risk Detection and Alerting System Based on Electronic Health Records using CogStack
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"The Process Is Built for Psychological Safety": Behavioral Health Providers' Experiences Using a Systems-Based

Margaret L McGladrey1, Tiffany Lindsey2, Scott Fairhurst3

  • 1Department of Health Management and Policy, University of Kentucky (UK) College of Public Health, Lexington, Kentucky.

Journal of Patient Safety
|December 24, 2025
PubMed
Summary

Learning from critical incidents in behavioral health settings requires empathetic facilitation and preparation to foster psychological safety and drive systems change. Including diverse staff and clear action timelines are key recommendations for effective incident reviews.

Keywords:
behavioral heath systemscritical incident reviewpsychological safetyquality improvement

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Area of Science:

  • Patient safety research
  • Healthcare systems improvement
  • Behavioral health services

Background:

  • Learning from critical incidents is vital for patient safety, focusing on system-level factors.
  • Promoting psychological safety in healthcare cultures is essential for addressing incident root causes.
  • Limited research exists on professionals' experiences with system-level critical incident reviews in behavioral health.

Purpose of the Study:

  • To explore practitioners' perceptions of a critical incident review tool in a behavioral health setting.
  • To understand how learning from critical incidents influences practice and safety culture.

Main Methods:

  • Mixed-methods study involving surveys and interviews.
  • Practitioners at a large California behavioral health agency participated.
  • The Safe Systems Improvement Tool was used to review critical incidents (suicides, overdoses, near misses).

Main Results:

  • Empathetic facilitation, preparation, and expectation-setting enhance psychological safety and support systems change during reviews.
  • Participants recommended including front-line, clinical, and supervisory staff.
  • Clear timelines for implementing recommendations are crucial for effective follow-up.

Conclusions:

  • Critical incident reviews in behavioral health can identify root causes and quality improvement opportunities.
  • These reviews foster psychological safety, reduce blame, and promote transparent system-wide transformation.
  • Effective reviews aggregate data, promote open assessment, and drive cultural change.