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. 2024;28(1):1-19.

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

Free full text

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

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

December 7, 2022

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

November 30, 2022

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

June 1, 2022

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

November 25, 2020

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

November 3, 2021

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

April 5, 2023

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

December 7, 2022

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

December 22, 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

For children admitted to hospital, what interventions improve medication safety on ward rounds?

March 1, 2023

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

September 30, 2020

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

March 3, 2021

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

February 16, 2022

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

December 16, 2020

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Differences in medication reconciliation interventions between six hospitals: a mixed method study.

June 29, 2022

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

October 13, 2021

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

April 19, 2017

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

September 14, 2022

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

November 16, 2022

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

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

November 2, 2022

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

May 26, 2021

Exploring the intersection of structural racism and ageism in healthcare.

December 7, 2022

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

July 13, 2022

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

November 24, 2021

Inpatient telemedicine and new models of care during COVID-19: hospital design strategies to enhance patient and staff safety.

September 15, 2021

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.

August 10, 2022

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

August 17, 2022

Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study.

May 11, 2022

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

September 28, 2022

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.

April 6, 2022

Trial and error: learning from malpractice claims in childhood surgery.

August 24, 2022

Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross-sectional survey.

May 11, 2022

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

August 10, 2022

The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial.

February 2, 2022

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

October 26, 2022

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Delayed access to care and late presentations in children during the COVID-19 pandemic: a snapshot survey of 4075 paediatricians in the UK and Ireland.

July 29, 2020

Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology.

November 18, 2020

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

July 27, 2022

Detectability of medication errors with a STOPP/START-based medication review in older people prior to a potentially preventable drug-related hospital admission.

December 21, 2022

What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study.

May 26, 2021

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

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

November 11, 2020

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

November 10, 2021

Associations of physicians’ prescribing experience, work hours, and workload with prescription errors.

November 18, 2020

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

November 9, 2022

Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting.

January 8, 2020

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

July 14, 2021

Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study.

December 9, 2020

Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19.

April 12, 2023

Patient safety implications of wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations.

February 15, 2023

Deferral of care for serious non-COVID-19 conditions: a hidden harm of COVID-19.

November 18, 2020

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

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

February 9, 2022

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices.

October 28, 2020

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.

January 12, 2022

An objective framework for evaluating unrecognized bias in medical AI models predicting COVID-19 outcomes.

June 1, 2022

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

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

August 17, 2022

Wellbeing, burnout, and safe practice among healthcare professionals: predictive influences of mindfulness, values, and self-compassion.

June 8, 2022

Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation.

February 17, 2021

A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges.

February 8, 2023

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.

July 27, 2022

Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity.

July 6, 2022

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

December 7, 2022

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: a systematic review of randomized trials and non-randomized intervention studies.

August 18, 2021

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

October 26, 2022

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

February 8, 2023

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

December 9, 2020

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

November 25, 2020

COVID-19: patient safety and quality improvement skills to deploy during the surge.

June 24, 2020

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

March 30, 2022

Changes in burnout and satisfaction with work-life integration in physicians over the first 2 years of the COVID-19 pandemic.

October 26, 2022

National cross-sectional cohort study of the relationship between quality of mental healthcare and death by suicide.

June 1, 2022

Development and implementation of a suicide prevention checklist to create a safe environment.

March 4, 2020

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

May 18, 2022

Criminal liability for nursing and medical harm.

August 3, 2022

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

October 19, 2022

Impact of pharmacist-led multidisciplinary medication review on the safety and medication cost of the elderly people living in a nursing home: a before-after study.

February 12, 2020

State medical board regulation of compounding in physician offices.

June 9, 2021

The source of purchased medications and its impact on medication mistakes and hospitalizations.

March 16, 2022

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives.

November 25, 2020

Physician task load and the risk of burnout among US physicians in a national survey.

December 2, 2020

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center.

August 12, 2020

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

December 14, 2022

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

April 20, 2022

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

November 30, 2022

A program to provide clinicians with feedback on their diagnostic performance in a learning health system.

October 28, 2020

Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic.

October 28, 2020

Mitigating the July effect.

July 7, 2021

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

August 17, 2022

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

March 23, 2022

COVID-19: the dark side and the sunny side for patient safety.

October 14, 2020

Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial.

December 2, 2020

Assessment of changes in visits and antibiotic prescribing during the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic.

July 20, 2022

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

Related Resources

Diagnostic error in mental health: a review.

April 24, 2024

Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients.

February 28, 2024

Abusive supervision and its relationship with nursing workforce and patient safety outcomes: a systematic review.

January 17, 2024

Validation and use of the Second Victim Experience and Support Tool questionnaire: a scoping review.

December 20, 2023

Challenge Competition: Impact of Patient Safety Tools.

December 12, 2023

Unequal Treatment Revisited: A Workshop Series.

September 26, 2023 - September 27, 2023

Defining speaking up in the healthcare system: a systematic review.

September 20, 2023

Racism in health services for adolescents: a scoping review.

August 2, 2023

An integrative systematic review of employee silence and voice in healthcare: what are we really measuring.

June 28, 2023

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review.

June 28, 2023

Systems approach to suicide prevention: strengthening culture, practice, and education.

June 28, 2023

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

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

Exploring the impact of employee engagement and patient safety.

September 14, 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

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

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

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

August 17, 2022

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

August 3, 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

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

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