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Mills PD, Watts BV, Hemphill RR. J Patient Saf. 2021;17:e423-e428.
Researchers reviewed 15 years of root cause analysis reports of all instances of suicide and suicide attempts on Veterans Health Administration (VHA) grounds. Forty-seven suicides or suicide attempts were identified, and primary root causes included communication breakdown and a need for improved suicide interventions. The paper includes recommended actions to address the root causes of attempted and completed patient suicides.
Cleary M, Lees D, Lopez V. Issues Ment Health Nurs. 2018;39:980-982.
Effective apology behaviors improve opportunities for error resolution for clinicians, patients, and families. This commentary highlights the importance of expressing empathy, considering legal implications, and demonstrating individual, leadership, and organizational support of open disclosure.