A review of modifiable health care factors contributing to inpatient suicide: an analysis of coroners' reports using the Human Factors Analysis and Classification System for Healthcare

Suicide is considered a never event in healthcare settings. Using data from 2009 to 2018, researchers used the Human Factors Analysis and Classification System (HFACS) for Healthcare to identify modifiable risk factors contributing to inpatient suicide in Australia. Common contributing factors include decision errors (e.g., failure to address patient deterioration), problems with the physical environment, and operational mismanagement (e.g., insufficient oversight of junior staff).