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- Never Events
Journal Article > Review
Tishler CL, Reiss NS. Gen Hosp Psychiatry. 2009;31:103-109.
Suicide attempts by inpatients are considered a never event, and, as such, are also considered reportable sentinel events by the Joint Commission. This article reviews the suicide rate in hospitals, related risk factors, methods of suicidal behavior, factors that contribute to the event, and suggestions for prevention and risk assessment.
Journal Article > Study
Mills PD, Watts BV, 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.
Journal Article > Study
A quality improvement initiative to reduce safety events among adolescents hospitalized after a suicide attempt.
Noelck M, Velazquez-Campbell M, Austin JP. Hosp Pediatr. 2019;9:365-372.
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.