Office of Mental Health

Incident Management Practices at Selected Psychiatric Centers

The Office of Mental Health (OMH) operates 28 psychiatric centers (Centers) that provide mental health services to an estimated 75,000 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 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, and to develop a written incident management plan.

We examined incident management practices at five selected Centers and found that the Centers were largely in compliance with the requirements for incident reporting and incident investigation. We also found that an appropriate incident management plan had been developed by each Center. However, improvements were needed in Center documentation practices, Center use of the automated incident reporting system, and OMH’s monitoring of information on the reporting system.

For a complete copy of Report 2003-S-53 click here.
For a copy of the 90-day response click here.
For a copy of the associated follow-up report click here.