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.
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.
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.
Mokkenstorm JK, Kerkhof AJFM, Smit JH, et al. Suicide Life Threat Behav. 2018;48:745-754.
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.
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.
Mills PD, DeRosier JM, Ballot BA, et al. Jt Comm J Qual Patient Saf. 2008;34:482-488.
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.
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