Office of Mental Health

Incident Management Practices at Selected Psychiatric Centers (Follow-Up Report)

The Office of Mental Health (OMH) operates 27 psychiatric centers that provide mental health services to an estimated 90,000 inpatients and outpatients annually. In the mental health field, an incident is defined as an event involving a client that has or may have an adverse effect on the life, health or welfare of the client and/or another person. The psychiatric centers are required to report all incidents promptly to OMH, and are also required to report certain types of incidents to various external parties, such as the Commission on Quality of Care and the client’s next of kin or legal guardian. The centers are also required to investigate all incidents promptly and thoroughly.

In audit report 2003-S-53, we examined incident management practices at five selected psychiatric centers and found that the centers were largely in compliance with the requirements for incident reporting and incident investigation. However, improvements were needed in the centers’ documentation practices and use of the automated incident reporting system, and in OMH’s monitoring of information on the reporting system. When we followed up on our recommendations for improvement, we found that they had been implemented.

For a complete copy of Report 2006-F-30 click here.