Six major steps to make investigations of suicide valuable for learning and prevention.

E Fröding; C Vincent; B Andersson-Gäre; Å Westrin; A Ros

Review

Six major steps to make investigations of suicide valuable for learning and prevention.

November 2, 2022

Fröding E, Vincent C, Andersson-Gäre B, et al. Arch Suicide Res. 2022;Epub Oct 19.

View more articles from the same authors.

Earlier research shows many investigations into suicide deaths are conducted to fulfill regulatory requirements, rather than to improve suicide-prevention interventions. This review identified six problems with investigations (e.g., failure to consider deeper system perspective) and proposed a new model of investigation which considers suicide a patient harm.

PubMed citation

Available at

Related Resources From the Same Author(s)

Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective.

March 31, 2021

Patient voices in hospital safety during the COVID-19 pandemic.

November 2, 2022

Exploring the intersection of structural racism and ageism in healthcare.

December 7, 2022

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

April 19, 2017

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

December 7, 2022

Ethical leadership supports safety voice by increasing risk perception and reducing ethical ambiguity: evidence from the COVID-19 pandemic.

November 9, 2022

Patient safety culture in assisted living: staff perceptions and association with state regulations.

November 30, 2022

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

How to do no harm: empowering local leaders to make care safer in low-resource settings.

March 3, 2021

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

December 7, 2022

Improving discharge safety in a pediatric emergency department.

October 26, 2022

Leveraging a safety event management system to improve organizational learning and safety culture.

March 30, 2022

Resident duty hours and resident and patient outcomes: systematic review and meta-analysis.

November 16, 2022

Patients' experience of patient safety information and participation in care during a hospital stay.

November 16, 2022

Rates of surgical consultations after emergency department admission in Black and White Medicare patients.

October 26, 2022

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory.

October 19, 2022

RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.

August 17, 2022

Mapping the resilience performance of community pharmacy to maintain patient safety during the Covid-19 pandemic.

February 16, 2022

Gender bias in risk management reports involving physicians in training - a retrospective qualitative study.

November 9, 2022

Factors influencing medication errors in the prehospital paramedic environment: a mixed method systematic review.

July 27, 2022

Predicting avoidable hospital events in Maryland.

December 1, 2021

State medical board regulation of compounding in physician offices.

June 9, 2021

Criminal liability for nursing and medical harm.

August 3, 2022

Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems.

December 14, 2022

Transformational improvement in quality care and health systems: the next decade.

November 25, 2020

Mitigating the July effect.

July 7, 2021

Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches.

November 30, 2022

Bracing for the storm: one health care system's planning for the COVID-19 surge.

November 11, 2020

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes.

June 1, 2022

Fall prevention with the Smart Socks System reduces hospital fall rates.

September 7, 2022

Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.

November 3, 2021

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study.

November 2, 2022

A call to action: next steps to advance diagnosis education in the health professions.

June 8, 2022

Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention measures.

April 20, 2022

Racial disparities in child abuse medicine.

November 3, 2021

Managing the aftermath of iatrogenic injury.

September 28, 2005

Missing the near miss: recognizing valuable learning opportunities in radiation oncology.

December 16, 2020

Nurse managers' leadership, patient safety, and quality of care: a systematic review.

September 21, 2022

Weight and size descriptors for drug dosing: too many options and too many errors.

January 11, 2023

Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'.

May 18, 2022

How to mitigate the effects of cognitive biases during patient safety incident investigations.

September 28, 2022

First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality.

March 3, 2021

Embracing multiple aims in healthcare improvement and innovation.

March 23, 2022

The critical role of health information technology in the safe integration of behavioral health and primary care to improve patient care.

November 10, 2021

Early diagnosis of cancer: systems approach to support clinicians in primary care.

April 5, 2023

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.

August 17, 2022

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

August 17, 2022

Shame and guilt in EMS: a qualitative analysis of culture and attitudes in prehospital emergency care.

July 13, 2022

Falling through the cracks: the invisible hospital cleaning workforce.

October 26, 2022

Experience of learning from everyday work in daily safety huddles: a multi-method study.

September 14, 2022

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

September 30, 2020

Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure.

February 8, 2023

Safer Healthcare: Strategies for the Real World.

February 24, 2016

Older patients' engagement in hospital medication safety behaviours.

June 16, 2021

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

December 9, 2020

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

July 6, 2022

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

June 30, 2021

Impact of the initial response to COVID-19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident reports.

October 14, 2020

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

June 8, 2011

Medication errors and processes to reduce them in care homes in the United Kingdom: a scoping review.

March 23, 2022

Patient Safety, 2nd edition.

August 4, 2010

Enhancing psychological safety in mental health services.

June 9, 2021

Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.

July 13, 2022

Paramedic self-reported medication errors.

October 18, 2006

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.

November 30, 2022

Influencing a culture of quality and safety through huddles.

November 9, 2022

Evaluation of older persons' medications: a critical incident technique study exploring healthcare professionals' experiences and actions.

June 23, 2021

Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study.

August 10, 2022

Using potentially preventable severe maternal morbidity to monitor hospital performance.

February 8, 2023

The Lancet Commission on lessons for the future from the COVID-19 pandemic.

October 12, 2022

How safe are paediatric emergency departments? A national prospective cohort study.

August 3, 2022

The abrupt expansion of ambulatory telemedicine: implications for patient safety.

February 9, 2022

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

November 3, 2021

Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.

June 22, 2022

Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies.

September 9, 2020

Teamwork before and during COVID-19: the good, the same, and the ugly….

August 24, 2022

'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.

November 24, 2021

Safety implications of remote assessments for suspected COVID-19: qualitative study in UK primary care.

March 23, 2022

Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90).

January 26, 2022

Using community detection techniques to identify themes in COVID-19-related patient safety event reports.

December 7, 2022

Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident technique analysis.

July 14, 2021

The Measurement and Monitoring of Safety.

May 8, 2013

Changes in unprofessional behaviour, teamwork, and co-operation among hospital staff during the COVID-19 pandemic.

September 28, 2022

Families’ experiences of central-line infection in children: a qualitative study.

September 7, 2022

Patient safety: what about the patient?

March 6, 2005

Systems Analysis of Critical Incidents: the London Protocol.

December 19, 2007

What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study.

January 19, 2022

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study.

May 5, 2021

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

A checklist to address implicit bias in healthcare settings during the COVID-19 pandemic: The PLACE Strategy.

June 8, 2022

Detecting and assessing suicide ideation during the COVID-19 pandemic.

May 26, 2021

Patient perceptions of safety in primary care: a qualitative study to inform care.

October 13, 2021

Healthcare personnel's working conditions in relation to risk behaviours for organism transmission: a mixed-methods study.

July 21, 2021

Potentially inappropriate medication administration is associated with adverse postoperative outcomes in older surgical patients: a retrospective cohort study.

September 14, 2022

Improving diagnosis: adding context to cognition.

September 7, 2022

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

December 22, 2021

Making Dialysis Safer for Patients Coalition.

August 30, 2017

National Healthcare Safety Network.

July 10, 2013

Opioid Overdose.

April 6, 2016

Racism and Health.

April 21, 2021

Related Resources

Structural racism in behavioral health presentation and management.

May 17, 2023

Person-first treatment strategies: weight bias and impact on mental health of people living with obesity.

April 19, 2023

Systematic review of clinical debriefing tools: attributes and evidence for use.

April 19, 2023

Crisis scenarios for simulation-based nontechnical skills training for cardiac surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists, and cardiac operating room nurses.

April 12, 2023

Care Delivery within Community Mental Health Teams.

April 5, 2023

Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda.

March 29, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

The role of bias in clinical decision-making of people with serious mental illness and medical co-morbidities: a scoping review.

February 22, 2023

The value of learning from near misses to improve patient safety: a scoping review.

January 25, 2023

Structural racism and adverse maternal health outcomes: a systematic review.

December 21, 2022

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

December 7, 2022

Patients who die by suicide: a study of treatment patterns and patient safety incidents in Norway.

November 9, 2022

The impact of electronic health record interoperability on safety and quality of care in high-income countries: systematic review.

October 5, 2022

Maybe they had a bad day: how LGBTQ and BIPOC patients react to bias in healthcare and struggle to speak out.

September 14, 2022

Exploring the impact of employee engagement and patient safety.

September 14, 2022

Alcoholism and American healthcare: the case for a patient safety approach.

August 17, 2022

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.

August 17, 2022

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

August 17, 2022

Employee silence in health care: charting new avenues for leadership and management.

August 3, 2022

Safety-II and the study of healthcare safety routines: two paths forward for research.

July 13, 2022

Instruments for measuring patient safety competencies in nursing: a scoping review.

June 15, 2022

Is it time for the mental health field to consider unplanned discharge a key metric of patient safety?

May 4, 2022

Factors associated with workplace violence among healthcare workers in an academic medical center.

April 27, 2022

Crossover of the patient satisfaction surveys, adverse events and patient complaints for continuous improvement in radiotherapy department.

April 20, 2022

Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18).

April 20, 2022

To what extent are patients involved in researching safety in acute mental healthcare?

April 6, 2022

Diagnostic error in pediatrics: a narrative review.

March 23, 2022

Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review.

February 16, 2022

Race as a social construct in psychiatry research and practice.

December 22, 2021

How do patients respond to safety problems in ambulatory care? Results of a retrospective cross-sectional telephone survey.

December 1, 2021

See More About The Topic

Ambulatory Clinic or Office

Quality and Safety Professionals

Mental Health Care (Psychiatry and Clinical Psychology)

Psychological and Social Complications

Epidemiology of Errors and Adverse Events

Six major steps to make investigations of suicide valuable for learning and prevention.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Six major steps to make investigations of suicide valuable for learning and prevention.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site