The Mental Health Program worked closely with the Quality Risk Management Department to develop a new model for the suicide process review. The model follows the Canadian Patient Safety Institute's (CPSI) Root Cause Analysis (RCA) Framework and advocates a multi-disciplinary approach by including participation of care providers outside the Mental Health Program (e.g., from other departments providing care, nursing homes). The benefits of this new approach to the suicide process review are many. The model facilitates a structured and consistent approach to investigation; supports a systematic process of data collection and analysis; identifies causes and contributing factors; and focuses on process and system vulnerabilities on mutual learning, not on individual performance.

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