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Donovan AL, Aaronson EL, Black L, et al. Jt Comm J Qual Patient Saf. 2021;47(1):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.  

Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30(7):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(8):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%).
Glauser G, Goodrich S, McClintock SD, et al. J Thorac Cardiovasc Surg. 2021;162(1):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.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No. 19-00468-67.
Systemic weaknesses challenge safe care in Veterans Affairs health systems facilities. This report analyzed a patient suicide at one medical center and determined contributors to the failure. This report shares recommendations to address deficiencies including improved communication across the care continuum and reliably acting on root cause analysis results.
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. 
Sentinel Event Alert. 2010;46:1-4.
Suicide among hospitalized patients remains an under-recognized never event, as it has ranked among the most common sentinel events reported to The Joint Commission over the past decade. While specialized psychiatric units are designed and staffed to minimize suicide risk, emergency departments and general medical wards are not, and prior research has shown that a significant proportion of inpatient suicide attempts occur in these settings. This Sentinel Event Alert reviews risk factors for inpatient suicide and delineates prevention strategies hospitals can use to minimize risk. A case of an inpatient suicide attempt on a general medical ward is discussed in this AHRQ WebM&M commentary. Note: This alert has been retired effective February 2016. Please refer to the information link below for further details.
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.
Mills PD, DeRosier JM, Ballot BA, et al. Jt Comm J Qual Patient Saf. 2008;34(8):482-488.
The Department of Veterans Affairs has pioneered the use of root cause analysis to identify systems causes of adverse events. This study reports on the use of this technique to analyze inpatient suicide attempts at VA hospitals. Suicide attempts, the majority of which occur on inpatient psychiatric units, are considered a health care never event. Review of root cause analysis reports over a 7-year period identified several methods of self-harm and factors that facilitated suicide attempts. A prior study reported on preventive mechanisms that have been implemented at VA hospitals to reduce the risk of inpatient suicide attempts.
Ballard ED, Pao M, Henderson D, et al. Jt Comm J Qual Patient Saf. 2008;34(8):474-481.
This review sought to differentiate suicides in hospitalized medical patients from suicides in psychiatric patients or the general population. Finding a shortage of detailed data, the authors call for more comprehensive research on in-hospital suicides to inform prevention strategies.