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Washington, DC: VA Office of the Inspector General;  February 17, 2022. Report No. 21-01506-76.

Patient suicide is a reoccurring sentinel event that is a challenge for the veteran’s health care community. This report shares the results of 36 unplanned inspections at United States Veterans Affairs facilities. While the inspections found general guidance compliance to be in place, weaknesses in required patient follow-up, staff training and outreach activities were flagged as areas in need of targeted improvement to enhance patient safety.
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.
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.
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%).

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.