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Oakbrook Terrace, IL: Joint Commission: October 2019.
Inpatient suicide is increasing as a safety concern. This case analysis offers two levels of examination of a hypothetical patient suicide: one that outlines points of failure in the patient’s care and the other that shares strategies to prevent the event from occurring. 

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.
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.