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Quality and research

Four Steps to Safety

Quality and research

Four Steps to Safety

Quality and research

Four Steps to Safety

Quality and research

Four Steps to Safety

Four Steps to Safety is a system for safer care that consists of the following four steps:

  1. Proactive care
  2. Patient engagement
  3. Teamwork
  4. Environment 

Each step is supported by evidence based clinical interventions which are helpful to implement to prevent violence and aggression.

Four Steps to Safety was developed jointly by clinicians, patients and carers at South London and Maudsley and Devon Partnership Trust, the aim is to improve safety with a specific focus on reducing violence and aggression on mental health wards. By using Four Steps to Safety we believe we can achieve better and safer care for our patients and better working environments for our staff.

As a system for safer care it should be used by all members of staff who are working with patients. To achieve maximum results, patients and their carers should also be actively involved in the process.

The Quality Improvement team has a training video on Four Steps to Safety.

Get in touch

Four Steps to Safety is part of the Quality Improvement Team at South London and Maudsley.  To get in touch please call us on 020 3228 5318 or email

Four Steps to Safety interventions

DASA is a risk assessment tool used to identify the likelihood of violence and aggression during each shift, this is used to inform clinical care.

How we involve patients

Staff are encouraged to explain to patients the purpose of using DASA, and that they are being monitored to proactively reduce the risk of their deterioration.

How we use DASA

DASA should be used for every patient for the first three days of admission to inform their care. After the initial three days, the multidisciplinary team should review DASA scores and agree the frequency of use for each patient.

All members of the multidisciplinary team have a responsibility to use DASA to identify escalating behaviours and to provide the appropriate care. DASA scores should be discussed at each handover and documented on ePJS as part of the shift notes.
A risk assessment should be completed within the first four hours of admission to your service to identify immediate risks and to develop a risk management plan.

How we involve patients

Staff are encouraged to involve patients and carers in the risk assessment and management plan, dependent on their presentation. The agreed plan should be communicated to the patient, their family and carers where appropriate.

How we use risk management

Although the risk assessment is completed within the first four hours of admission by either a doctor or nurse it should be reviewed and updated regularly (by any member of the multidisciplinary team). Risk should be discussed in all handovers and ward rounds and communicated regularly with the patient and staff.
We use zoning which is a 'RAG rated' system where patients are zoned in red, amber or green. The colours help us allocate patients according to risk criteria, this helps us to plan interventions.

  • Patients in the red zone are high risk
  • Patients in the amber zone may be at risk of relapse
  • Patients in the green zone have a stable mental state

How we involve patients

Staff are encouraged to explain to patients the purpose of zoning, and that they are being monitored to proactively reduce the risk of their deterioration.

How we use zoning

On admission patients are likely to be in the red zone and it is the responsibility of the multidisciplinary team to review the zone with the patient on a regular basis. For each zone there are interventions to reduce the risk of further deterioration. Zoning is used at every handover meeting and can be used in conjunction with DASA.
Mutual agreement is an expectations document co-produced with patients and staff around the values and expectations of how they will work together to ensure that everyone feels respected, supported, valued and safe. This agreement is displayed openly on the ward.

How we involve patients

Patients and staff are encouraged to regularly discuss the content of the mutual agreement document in planning and community meetings. It is a live document and can be updated at any time.

How we use mutual agreement

The mutual agreement document should be created within in a community meeting with all staff and patients present. Everyone should be encouraged to contribute to the document. It might be helpful to use the document at the start of each community and planning meeting as a reminder of how everyone has agreed to work together.
Proactive engagement is an opportunity to build a rapport with patients and engage with them on each shift. This includes introducing yourself at the beginning of your shift and ensuring that you identify time to have a one to one conversation.

How we involve patients

Patients should expect to be approached by their allocated staff member and should also be encouraged to talk to them and any other member of staff during each shift.

How we use proactive engagement

The nurse in charge should ensure that any member of staff who is allocated patients during their shift use proactive engagement at least once in that shift and document it in the patient’s notes.
A report out board is a visual tool (often a whiteboard) used to update the team on specific tasks, who in the team is responsible for each task and when it should be completed.

How we involve patients

Patients should know that they are being cared for by a multidisciplinary team working together to ensure that their needs are being met.

How we use the report out board

All member of staff are expected to update the report out board when needed. During the multidisciplinary team meeting the board should be updated, this could be done by the nurse in charge or an identified member of staff who should ensure that the tasks allocated to individual team members are completed. The report out board should be updated on a shift by shift basis.
SBARD is a communication method used by staff for all handovers and reporting of incidents: 

S Situation
B Background
A Assessment
R – Recommendation
D – Decision

How we involve patients

Patients should be informed that information regarding their care is handed over within each shift using this method.

How we use SBARD

SBARD should be used verbally by reporting what’s significant, relevant and important to handover. SBARD can be used as a verbal hangover method and/or a written structured technique for end of shift notes documentation.
Escalating risk is a protocol to follow in the case of an emergency on the ward.

How we involve patients

We involve patients as part of their risk management planning and identifying how we will escalate risk.

How we use escalating risk

The team agrees on a set of identified actions which need to be taken in the event of a deteriorating patient (both mental and/or physical deterioration).
Safewards is a package of interventions which help teams to understand how certain types of environmental factors may lead to violence and how that can be changed.

How we involve patients

It is important to consider the views of the patient when it comes to choosing interventions from Safewards to improve the environment.

How we use Safewards

Below is a list of 10 interventions that wards can use. All members of the team including staff and patients should be involved in deciding which intervention will be relevant to their ward.

  1. Clear mutual expectations
  2. Soft words
  3. Talk down
  4. Positive words
  5. Bad news mitigation
  6. Know each other
  7. Mutual help meeting
  8. Calm down methods
  9. Reassurance
  10. Discharge messages 

Visit for information on the interventions.