Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
Commonly Searched Resource Types
1 - 7 of 7
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.
Berg SH, Rørtveit K, Walby FA, et al. BMJ Open. 2020;10:e040088.
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.   
Wyder M, Ray MK, Roennfeldt H, et al. Int J Qual Health Care. 2020;32:285-291.
This systematic review examined common systems factors affecting suicide deaths in mental health care. Seven themes contributing to suicide deaths were identified: (1) inappropriate or incomplete risk assessment; (2) lack of family involvement; (3) inadequate transitions and communication between different care teams; (4) lack of adherence to policies and procedures; (5) treatment not in line with current guidelines; (6) access to means and observation and; (7) lack of specialist services within the community.
A woman with a history of depression, anxiety, and posttraumatic stress disorder presented to the emergency department after a suicide attempt. Physical examination was significant for depressed affect and superficial lacerations to the bilateral forearms. Her left forearm laceration was sutured and bandaged with gauze. A psychiatrist evaluated her and placed an involuntary legal hold. Upon arrival to the inpatient psychiatric unit, the patient asked to use the bathroom. She unwrapped her wrist bandage, wrapped it around her neck and over the shower bar, and tried to hang herself.
Admitted to the hospital complaining of difficulty breathing and swallowing, a Vietnamese man was diagnosed with reflux disease and an outpouching of the esophagus. The patient was anxious and repeatedly stated that he was "dying" from his physical ailments. During a gastroenterology consultation, the patient ran to the restroom and jumped out the window, killing himself.
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.