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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.
A woman with a history of depression, anxiety, and posttraumatic stress disorder presented to the emergency department after a suicide attempt. Physical examination was significant for depressed affect and superficial lacerations to the bilateral forearms. Her left forearm laceration was sutured and bandaged with gauze. A psychiatrist evaluated her and placed an involuntary legal hold. Upon arrival to the inpatient psychiatric unit, the patient asked to use the bathroom. She unwrapped her wrist bandage, wrapped it around her neck and over the shower bar, and tried to hang herself.
Kanerva A, Lammintakanen J, Kivinen T. Perspect Psych Care. 2016;52:25-31.
Although patient safety has been a focus of nursing care in hospitals, this study found significant gaps in nurses' perceptions of patient safety in psychiatric inpatient units. For example, none of the interviewed nurses mentioned the importance of preventing inpatient suicide, which was the topic of a recent Joint Commission sentinel event alert.
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.
Cullen SW, Nath SB, Marcus SC. Psychiatr Q. 2010;81:197-205.
The authors used focus groups and interviews to develop a taxonomy of errors in inpatient psychiatry and explore underlying systems causes of the errors. Medication errors, diagnostic errors, and failure to prevent patient harm (such as suicide attempts) were among the common types of errors identified.