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Amit Aharon A, Fariba M, Shoshana F, et al. J Clin Nurs. 2021;30:3290-3300.
Patient suicide attempts or completions can have negative psychological impacts on the nurses involved. This mixed-methods study found a significant association between emotional distress and feeling alone with absenteeism and higher staff turnover. Healthcare organizations should develop support programs for second victims to increase resiliency and potentially decrease absenteeism and turnover.
Shao Q, Wang Y, Hou K, et al. J Adv Nurs. 2021;77:4005-4016.
Patient suicide in all settings is considered a never event. Nurses caring for the patient may experience negative psychological symptoms following inpatient suicide. This review identified five themes based on nurses’ psychological experiences: emotional experience, cognitive experience, coping strategies, self-reflection, and impact on self and practice. Hospital administrators should develop education and support programs to help nurses cope in the aftermath of inpatient suicide.  
Berg SH, Rørtveit K, Walby FA, et al. BMJ Open. 2020;10:e040088.
Patient safety is an emerging focus within the mental health field. This qualitative study highlights three themes of perceived safe clinical care for patients in a suicidal crisis – being recognized as suicidal, receiving personalized treatment, and adapting care to meet fluctuating behaviors.   
Donovan AL, Aaronson EL, Black L, et al. Jt Comm J Qual Patient Saf. 2021;47:23-30.
Patient suicide, attempted suicide, or self-harm are considered ‘never events.’ This article describes the development and implementation of a safety protocol for emergency department (ED) patients at risk for self-harm, including the creation of safe bathrooms and increasing the number of trained observers in the ED. Implementation of the protocol was correlated with lower rates of self-harm.  
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30:567-576.
This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.
Wyder M, Ray MK, Roennfeldt H, et al. Int J Qual Health Care. 2020;32:285-291.
This systematic review examined common systems factors affecting suicide deaths in mental health care. Seven themes contributing to suicide deaths were identified: (1) inappropriate or incomplete risk assessment; (2) lack of family involvement; (3) inadequate transitions and communication between different care teams; (4) lack of adherence to policies and procedures; (5) treatment not in line with current guidelines; (6) access to means and observation and; (7) lack of specialist services within the community.
Gill S, Mills PD, Watts BV, et al. J Patient Saf. 2021;17:e898-e903.
This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency departments at Veterans Health Administration hospitals over a two-year period. Of the 144 cases identified, the majority involved delays in care (26%), elopements (15%), suicide attempts and deaths (10%), inappropriate discharges (10%) and errors following procedures (10%). RCA revealed that primary contributory factors leading to adverse events were knowledge/educational deficits (11%) and policies/procedures that were either inadequate (11%) or lacking standardization (10%).
Frost DA, Snydeman CK, Lantieri MJ, et al. Psychosomatics. 2019;61:154-160.
This study assessed the effectiveness of a suicide prevention checklist in a single hospital developed based on Joint Commission recommendations. In the two years following checklist implementation, suicide attempts decreased by 42% (compared to the preceding two years); the number of patients sustaining temporary or minor injuries also decreased by 57% across the same time period. Survey responses showed that unit nurses felt the checklist list created a safe environment (88%) and that it supported consistent practice (90%) of caring for potentially suicidal patients in nonpsychiatric units.
Glauser G, Goodrich S, McClintock SD, et al. J Thorac Cardiovasc Surg. 2021;162:155-164.e2.
Surgical overlap is a longstanding practice, and reports suggest a link to postoperative complications and patient safety. This study measured the impact of overlap on patient outcomes among patients undergoing cardiac surgical interventions over a two-year period and found that overlap did not predict mortality, readmission, reoperation or emergency department visits at 30- or 90-days post-discharge, compared to patients without surgical overlap.
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.
Oliva EM, Bowe T, Tavakoli S, et al. Psychol Serv. 2017;14:34-49.
Opioid-related harm is an urgent patient safety priority. Identifying patients at higher risk of harm is a critical aspect of opioid safety. This quality improvement team developed a predictive model, based on electronic health record data, to identify high-risk opioid users in order to provide targeted monitoring and intervention via a clinical decision support tool. The model included known risk factors for opioid-related harm, such as type of medication, dose, and coprescribed sedating medications as well as medical and mental health conditions. Investigators developed and validated the model using data from 2010 and tested its ability to predict overdose or suicide attempt in 2011. The model successfully and prospectively identified patients at risk for suicide attempt or overdose. They then used the electronic health record to provide physicians with an overdose or suicide risk estimate and a checklist of risk mitigation strategies at the point of care. The authors suggest that further study of the implementation of this risk mitigation strategy in primary care is needed.
Brennan PL, Del Re AC, Henderson PT, et al. Transl Behav Med. 2016;6:605-612.
Opioids are considered high-risk medications and overdoses are common. Guidelines have been developed to facilitate safe prescribing practices. This study across 141 facilities within the Department of Veterans Affairs (VA) health system demonstrated that as adherence to urine drug screening guidelines increased from 2010 to 2013, the risk of suicide and overdose events among VA patients receiving prescription opioids decreased over the same period. The authors conclude that opioid therapy guidelines may have a positive impact on patient safety.
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.
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.
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.
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.
Cheng I-C, Hu F-C, Tseng M-CM. Gen Hosp Psychiatry. 2009;31:110-5.
Suicide attempts by hospitalized patients are considered a never event. This study examined 110 such cases and sought to identify predictors of suicide attempts among inpatients.
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.