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.   

Patients hospitalized after a suicide attempt may be at increased risk for self-harm. In this quality improvement study, researchers describe a multifaceted effort designed to reduce safety events among adolescents hospitalized for a suicide attempt.

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.

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.

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.

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.

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.

This study examined inpatient suicides at Veterans Affairs hospitals and provided recommendations for mitigating risks. Hanging by using equipment present in psychiatric wards was the most common method of suicide.

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.

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.

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.

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.