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Published Online:https://doi.org/10.1176/ajp.121.8.763

The nature and frequency of untoward events occurring on an open ward psychiatric unit in a general hospital over a one-year period is described, and the age-sex distribution is discussed. It is pointed out that the unit concerned accepts an unusually wide range of psychiatric conditions. The value of an unusual occurrence form to record such events is stressed. It is argued that a number of such occurrences must be expected on a well run liberal unit and that excessive precautions may be harmful to patients. Using the system outlined it is possible to review and eliminate such events as medication errors and to make comparisons between the number of unusual occurrences under different conditions.

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