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A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring.
Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146.
Washington DC: Department of Veterans Affairs, Office of Inspector General; May 10, 2023. Report no. 22-01116-110.
A 25-year-old female was sent by ambulance to the emergency department (ED) by a mental health clinic for suicidal ideation. Upon arrival to the ED, she was evaluated by the triage nurse and determined to be awake, alert, calm, and cooperative and she denied current suicidal thoughts. The ED was extremely busy, and the patient was placed on a gurney with a Posey restraint in the hallway next to the triage station awaiting psychiatric social work assessment. Approximately 40 minutes later, the triage nurse noticed that the patient was missing from the gurney.
Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.
An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting psychiatrist evaluated the patient but recommended sending her home on a benzodiazepine alone, under observation by her mother.
Schorsch K, Karp S. WBEZ Chicago. March 9, 2023.
Derfel A. Montreal Gazette. February 24- March 1, 2023
Washington, DC: VA Office of the Inspector General; February 17, 2022. Report No. 21-01506-76.
Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893.