BACKGROUND:
An adverse event (AE) is defined as an incident that results in harm to health, which may be physical, psychological, or social in nature1. The occurrence of AE can be explained by the “Swiss cheese” theory, where the holes in the cheese represent the flaws in the healthcare system2. These flaws can be attributed to several factors: inadequate training of professionals, lack of materials, stress, communication failures, work overload, among others. The objective of this study was to synthesize evidence on adverse events occurring in mental health services.

METHODS:
integrative literature review, with a survey of publications from 2015 to 2023, using the Medical Literature Analysis and Retrieval System Online, Latin American and Caribbean Health Sciences Literature, and Nursing Database. The following Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH) were used: “Medical Errors,” “Near Miss, Healthcare,” “Medication Errors,” “Mental Health Services,” “Mental Health Assistance,” and “Hospitals, Psychiatric.”

RESULTS:
735 articles were analyzed, and after applying the inclusion criteria, the final sample consisted of 7 articles, with the selected publications predominantly Brazilian. The study showed that the most common AEs in mental health services are caused by errors in the lack of professionals, physical management, prescription, and administration of medications. Psychiatric patients may be more susceptible to risky behaviors that can result in adverse events. Physical restraint, although sometimes necessary, can pose serious risks, such as asphyxiation or injury. In addition, medication administration errors are a significant cause of adverse events, with dosing errors and omissions being the most frequent.

CONCLUSIONS:
Few studies address the topic of AE in mental health, making further research on the subject necessary in order to strengthen patient safety measures.