From Sentinel Event to Systemwide Improvement: Development of the Behavioral Health No Harm Index

Behavioral health has largely remained outside the mainstream of harm measurement science. Traditional safety measurement tools such as the Global Trigger Tool or the Preventable Harm Index are not adapted for psychiatric care, where harm may manifest differently than traditional acute medical care settings. The aim of this study was to design, implement, and evaluate a Behavioral Health No Harm Index (BH-NHI) across inpatient, outpatient, and residential settings to enhance error detection, increase safety event reporting, develop a baseline for harm measurement, and establish a standardized review process for psychiatric care.

Following a sentinel event in summer 2022, a multidisciplinary team developed the BH-NHI through literature review, stakeholder engagement, and iterative refinement. The index was implemented across all MaineHealth Behavioral Health (MHBH) settings with high reliability organization (HRO) training, staff education, and the launch of the "Good Catch" initiative. Analysis of safety event reports across three fiscal years (FYs)-October 2021 through September 2024-examined baseline trends in harm events, severity levels, and event categories.

Safety event submissions increased 88.2% from FY22 to FY24, reflecting our goal to increase harm event reporting. Concurrently, the rate of BH-NHI events decreased from 26.7 to 18.3 per 1,000 safety events submitted. Variation in the BH-NHI event frequency represents early descriptive findings during initial implementation, and additional data will be required to establish a casual harm reduction.

The BH-NHI provides a replicable framework for behavioral health organizations to systematically increase detection and review harm events while building upon available literature related to harm measurement science and fostering a proactive safety culture aligned with HRO principles.