https://doi.org/10.1177/0004867417700732 Australian & New Zealand Journal of Psychiatry 1–3 DOI: 10.1177/0004867417700732 © The Royal Australian and New Zealand College of Psychiatrists 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav journals.sagepub.com/home/anp Australian & New Zealand Journal of Psychiatry Targeting Zero is a report commis- sioned by the Department of Health and Human Services (DHHS) pub- lished in October 2016. It was com- missioned as a result of a cluster of perinatal deaths at Djerriwarrh Health Service during 2013 and 2014 (Targeting Zero, ©State of Victoria, October 2016, ISBN: 978-0-7311- 6966-5; www2.health.vic.gov.au/hospi- tals-and-health-services/quality-safety- service/hospital-safety-and-quality- review). Targeting Zero concluded that clinical governance around moni- toring and responding to adverse clini- cal outcomes in a timely manner was inadequate and that DHHS lacked processes that were capable of detect- ing significant deficiencies in clinical governance, particularly regarding safety and quality. It found that across health services, avoidable patient harm continues to occur and variability of care is prevalent at an unacceptable level. Avoidable patient harm was defined as harm that patients suffer, not through their illness or a lack of knowledge about treatment, but because of ineffective systems to help keep them safe while receiving care. Variability of care indicates that valua- ble knowledge is not being shared and implemented widely, so that many patients are receiving care that diverges from best practice. High-level recommendations around mental health care included the need to ensure adequate mental health funding and that there is public discus- sion regarding indicators pertaining to safety, quality and pressure on Mental Health Services (MHS) in order to prevent avoidable harm and reduce variation in practice. This debate article takes a balcony view of safety and quality within men- tal health to consider in more detail the issues of avoidable harm, variabil- ity of care leading to divergence from best practice and hopes to facilitate a public discussion among psychiatrists regarding what are important indica- tors of safety, quality and pressure within MHS. Safety and quality within MHS Avoidable harm Within specialist MHS, some types of avoidable harm that regularly occur within inpatient services are shown in Table 1. Rates of seclusion for some services are presented in Table 2 and are pub- licly available and documented within the Office of the Chief Psychiatrist’s Annual Report (2015–2016, Victorian Government, 1 Treasury Place, Melbourne, ©State of Victoria, Department of Health and Human Services, November 2016, ISSN: 2207- xxxx; www2.health.vic.gov.au/about/ key-staff/chief-psychiatrist/annual- reports). The reports of the Mental Health Complaints Commission (Annual Report 2015–2016, www. mhcc.vic.gov.au/downloads/2015- 16%20Annual%20Report.pdf) and the Community Visitors Annual Report on Public MHS (2015–2016, ©2016, Office of the Public Advocate, ISSN 1836- 3296; www.publicadvocate.vic.gov.au/ our-services/publications-forms/368- community-visitors-annual-report- 2015-2016?path) demonstrate the concerns that our consumers have for their safety in psychiatric settings. Firm data regarding frequency of occurrence are not readily available for many adverse outcomes. An online survey published in 2013 of Victorian women admitted to psychiatric wards found 45% reported being victims of sexual assault during their admission (Mental Health Services Annual Report 2015– 2016, Victorian Government, ©State of Victoria, Department of Health and Human Services October 2016, ISSN 2206-5970; www2.health.vic.gov.au/ Api/downloadmedia/%7B7DB669B0- 9714-4CA0-A5D8-5B8E17849E3C%7D). Kulkarni (Zero Tolerance for Sexual Assault, 2013 Victorian Mental Illness Awareness Council; www.abc.net.au/ reslib/201305/r1115028_13591277. pdf) suggests that 5–11% of women in psychiatric inpatient units experience significant sexual harassment and/or assault. A 2015 meta-analysis of suicide among psychiatric inpatients found vari- ability in reported rates and estimated across 39 studies that there is one inpa- tient death per 676 admissions (Walsh Targeting Zero: Implications for public psychiatric services J Richard Newton 1,2,3 , Peter Bosanac 1 , David Copolov 3 , Malcolm Hopwood 1 , Nick Keks 2 , Nick Paoletti 1 , John Tiller 1 and David Castle 1 1 The University of Melbourne, Melbourne, VIC, Australia 2 Mental Health Service, Austin Health, Heidelberg, VIC, Australia 3 Monash University, Clayton, VIC, Australia Corresponding author: J Richard Newton, Mental Health Service, Austin Health, PO Box 5555, Heidelberg, VIC 3084, Australia. Email: richard.newton@austin.org.au 700732ANP 0 0 10.1177/0004867417700732ANZJP DebateNewton et al. research-article 2017 Debate