Cases & Commentaries

The Dangerous Detour

Commentary By Josh Gibson, MD; David H. Taylor, MD

The Case

Following an overdose of alcohol and Ativan, a
26-year-old woman was admitted to the Medicine service for
observation after being placed on a 72-hour hold by Psychiatry. Per
hospital policy, a 24-hour sitter was placed with the patient.

The patient was to be accompanied to Radiology
for a chest film and asked to go to the bathroom first. The
transport and sitter were in the room when the nurse left the room
to get the chart, which would go down with the patient. The sitter
and transporter began to chat. The nurse returned and became
concerned that the patient was still in the bathroom. She opened
the bathroom door to find the patient with her gown tied around her
neck and the door hinge. The patient was standing on the
upside-down garbage can and was seconds from stepping off and
hanging herself. The patient was unharmed; she was stopped in

The Commentary

This case illustrates the risk to safety that can
arise when patients with acute psychiatric symptoms are admitted to
a medical/surgical unit. Fortunately, no harm came to this patient,
but this “near miss”
provides an ideal opportunity to discuss how best to provide for
the safety of a suicidal patient in a non-psychiatric acute care

From 1995 to early 2003, 324 inpatient suicides
were reported in US institutions.(1)
This number, drawn from a national “sentinel event”
database, represents a significant under-estimate, compared with
numbers drawn from the psychiatric literature. One article on the
epidemiology of suicide suggests that among the roughly 30,000
suicides occurring each year in the US, approximately 1,500
suicides (5%) occur in hospitals.(2) A
recent review of 76 cases in the US (2) revealed that only 40% of inpatients who committed
suicide had been admitted because of suicidal ideation.

Since both the team and the patient admitted to
medical or surgical services generally seek improved health, the
systems guiding inpatient medical care have been built to support
that goal. Such systems are typically geared toward identifying and
responding to signs of distress through a number of means,
including those that are automated (eg, electronic monitors or
alarms), provider-initiated (eg, physical exam or interview), and
patient-initiated (eg, calls for help or reports of

The suicidal patient is atypical in this
Such a patient may not choose to be helped toward health, or even
to be passively monitored while on that path. Importantly, the
suicidal patient did not share the goal of the treatment team prior
to admission (having recently tried to end his or her life) and
quite likely maintains significant ambivalence about living.

How does the general acute hospital system deal
with such an atypical patient? No automated system or lab test can
provide useful information about suicide risk. Provider-initiated
exams are useful, but prediction of suicide in an individual
patient remains difficult.(2)
False positive assessments cause indirect harm to patients by
squandering scarce resources, while false negative assessments pose
direct threats, as patients may receive inadequate protections.
Patient-initiated calls for help are unlikely with the truly
suicidal. Clearly, the typical systems in place will not function
adequately to protect the safety of a suicidal patient.

For patients admitted to a medicine service
following a serious suicide attempt who are judged an ongoing
suicide risk, the usual solution has been continuous observation by
a “sitter,” as in this case. Typically, these sitters
lack formal medical, nursing, or psychiatric training.(4)
They function, in effect, as monitors able to call for help when an
unsafe situation presents itself. As this case demonstrates,
continuous observation by a sitter has shortcomings that jeopardize
patient safety. In essence, we are witness to a serious human factors
problem in which the most immediately responsible member of the
team is unfamiliar with the unit, unknown to the rest of the team,
and ill-prepared to manage a very intense psychiatric

Little literature exists regarding a “best
practice” for treating suicidal patients on the medical ward,
but aspects have been addressed separately in a number of studies,
often specific to the psychiatric ward. A recent survey suggested
that continuous observation procedures on psychiatric units are
more effective at keeping suicidal patients safe (6), but many patients still commit suicide.(6) The
challenges of keeping suicidal inpatients safe were made clear in a
Canadian review of 100 inpatient suicides, which found that most
medical ward suicides occurred in the first 7 days of admission and
that suicides on the medical ward were significantly less
predictable than those on psychiatric wards.(7) Given systems concerns and existing evidence,
components of a “best practice” should address: the
physical environment, administrative procedures, continuous
observation procedures, suicide risk assessment, and the
relationship between the patient and the treating team.

The physical environment of the
psychiatric ward typically includes safety design features such as
unbreakable mirrors, unbreakable windows with limited ability to
open, and protuberances (eg, shower rods) that give way at low
weight loads. Nonetheless, no unit is “suicide
Suicidal patients can and do examine the layout of a psychiatric
ward to assess the lethal means that may be available to them, and
they often perceive environmental safeguards as evidence of caring
on the part of the staff.(9) As
new medical/surgical facilities are constructed, they should be
designed as suicide resistant. We also propose that, just as signs
such as “Fall Risk” or “Seizure
Precautions” are posted in and outside patient rooms, signs
saying “Continuous Behavioral Observation” should be
posted for suicidal patients. These signs would alert any member of
the treatment team (including ancillary staff, such as the
transport person in this case), that the patient should
never be unaccompanied. Of course, training for all staff
(including nonclinical personnel) regarding what “Continuous
Observation” means should be undertaken.

Administrative procedures can also migrate
from the psychiatric ward to the medical inpatient setting. A
personal search of the patient and the patient’s belongings
should always take place to remove dangerous articles of clothing.
Visitors should be supervised to ensure no transfer of potentially
lethal means including prescriptions from home. Standard order sets
would minimize risk to patients and serve as the basis for care
guidelines. Such orders must be clear and explicitly spell out what
the treatment team needs to do (eg, “Patient must be observed
continuously. Provide same gender observer for
toileting/bathing.”).(10) A
suicidal patient unattended in a bathroom is as risky as a person
with a recent hip fracture unattended in a bathroom: both are
accidents waiting to happen.

Continuous observation procedures for
psychiatric wards lack standardization and use inconsistent
Often these focus on clerical fulfillment of checklists rather than
true care or patient safety.(12)
Each hospital should have a set of clearly defined protocols for
continuous observation, and all members of the treatment team
should be aware of their roles. While costs would be higher if
mental health technicians were employed as sitters on medical
wards, patient safety would be improved.

Risk assessment remains a critical part of
caring for suicidal medical inpatients, but it lacks precision.
Suicidality should be assessed regularly, as a vital sign,
in such patients, just as pain assessment is now managed.
Psychiatric consultation should also be utilized regularly in
decision-making by the treatment team, which retains primary
responsibility for patient safety.

The suicidal patient’s relationship with
the treatment team plays a critical role in safety. All too
often, there is palpable contempt for the recently suicidal
individual who is perceived as creating unnecessary work for the
team, using valuable resources that could be devoted to the
“truly” ill, and trying to die when the team’s
goal is to help people live. These perceptions only sharpen
patients’ shame and rage at their own predicament and are not
only traumatic but probably pro-suicidal. The team’s
attitudes and interactions with the patient therefore influence the
patient’s decision-making about suicide. Patients who feel
the team cares for and understands them are more likely to report a
sense of personal value and a decrease in suicidal

Gibson, MD
Student Health Services
University of California, San Francisco

David H. Taylor,
Medical Services Director
Clinical Services Development
University of California Office of the President


1. Sentinel Event Statistics. Vol. 2003: Joint
Commission on Accreditation of Healthcare Organizations; 2003.

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