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Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195.

Hospitalized patient suicide is a sentinel event. This report describes an investigation into a patient suicide incident in the Veterans Affairs health system that found numerous conditions that contributed to the event, such as nonoperational security cameras, ineffective rounding policy, and lack of leadership knowledge of safety practices in mental health units. Recommendations for improvement include staff education, standardization of rounding, and robust oversight of frontline practice.
Mokkenstorm JK, Kerkhof AJFM, Smit JH, et al. Suicide Life Threat Behav. 2018;48:745-754.
Suicide in all settings is considered a sentinel event. This commentary describes an aspirational suicide eradication program. The approach combines direct identification of suicidal behavior and treatment, system-focused process improvements, and organizational safety culture as interdependent strategies for eliminating suicide. A previous WebM&M commentary discussed a suicide attempt on an inpatient medical unit.
Williams SC, Schmaltz SP, Castro GM, et al. Jt Comm J Qual Patient Saf. 2018;44:643-650.
The Joint Commission identifies inpatient suicide as a sentinel event. Little is known about the epidemiology of hospital suicides other than that they are rare and occur mostly in psychiatry wards. Researchers examined two national databases to develop the first data-driven appraisal of hospital suicide rates. Nationally, between 49 and 65 hospital suicides occur each year. Nearly 75% happen during psychiatric treatment, and the most common means of death is hanging. This hospital suicide rate is an order of magnitude lower than prior estimates. An accompanying editorial raises concerns about the much larger epidemic of suicide immediately after psychiatric hospital discharge. A prior WebM&M commentary highlighted additional strategies to reduce hospital suicide risk.
Sentinel event alert. 2016:1-7.
The Joint Commission publishes sentinel event alerts to emphasize pressing safety issues, determine root causes, and provide guidelines for organizations on how to address them. In light of receiving 1089 reports of suicide between 2010 and 2014, this new alert focuses on preventing suicide in health care settings. Many of the suicide cases investigated across health care settings had involved inadequate assessments or lack of identification of suicidal ideation. The alert suggests that all health care providers should screen for suicidal ideation and review patients for suicide risk factors. A previous WebM&M commentary discusses a suicide attempt on an inpatient medical unit. Note: This alert has been retired effective February 2019. Please refer to the information link below for further details.
Mills PD, Watts V, Hemphill RR. J Hosp Med. 2014;9:182-5.
A suicide attempt by a hospitalized patient is considered a never event. The majority of inpatient suicides occur in psychiatric units, but a prior Joint Commission sentinel event alert suggested that nearly 15% of attempts happen on medical wards. This study reviewed root cause analysis reports of suicide attempts on medical units in the Veterans Health Administration between 1999 and 2012. Fifty cases were identified and five represented completed suicides. Alcohol withdrawal was the most common reason for admission among patients who attempted suicide while hospitalized. The case reviews revealed communication failures, such as lack of discussion about suicide risks or mitigation plans during handoffs to other medical providers, as common contributors to these events. The authors recommend improved staff education, standardized communication for suicide risk, and protocols for appropriate management of suicidal patients. A prior article provided further implementation strategies for avoiding inpatient suicides.
Mills PD, Watts V, Miller S, et al. Jt Comm J Qual Patient Saf. 2010;36:87-93.
Suicide in a hospitalized patient is considered a never event. The majority of inpatient suicide attempts occur in patients hospitalized on psychiatric units, and a prior study conducted in Veterans Affairs hospitals used root cause analysis to identify predisposing factors for suicide attempts. Based on those findings, in this study, the authors report on the development of a checklist to identify and minimize suicide hazards in mental health facilities. The checklist primarily focused on eliminating environmental hazards, such as anchor points for hanging attempts and materials that could be used as weapons. After implementation of the checklist, over three-quarters of potential hazards were removed. A case of a suicide attempt on a medical unit is discussed in an AHRQ WebM&M commentary.
Tishler CL, Reiss NS. Gen Hosp Psychiatry. 2009;31:103-9.
Suicide attempts by inpatients are considered a never event, and, as such, are also considered reportable sentinel events by the Joint Commission. This article reviews the suicide rate in hospitals, related risk factors, methods of suicidal behavior, factors that contribute to the event, and suggestions for prevention and risk assessment.