Since the Joint Commission enacted its Sentinel Event Policy two years ago, the Accreditation Committee of the Joint Commission's Board of Commissioners has reviewed 65 cases related to inpatient suicides. A root cause analysis was completed for each of the events reviewed. Most of the suicides occurred in psychiatric hospitals (34), followed by general hospitals (27) and residential care facilities (4). Of those cases in general hospitals, 14 occurred in psychiatric units, 12 in medical/surgical units and one in the emergency room.
In 75 percent of the cases, the method of suicide was a hanging in a bathroom, bedroom or closet. Twenty percent of the suicides resulted from patients jumping from a roof or window.
Root Cause Analyses Conducted
Root causes of inpatient suicides that the organizations identified include:
- The environment of care, such as the presence of non-breakaway bars, rods or safety rails; lack of testing of breakaway hardware; and inadequate security.
- Patient assessment methods, such as incomplete suicide risk assessment at intake, absent
- or incomplete reassessment, and incomplete examination of the individual (for example, failure to identify a contraband).
- Staff-related factors, such as insufficient orientation or training, incomplete competency review or credentialing, and inadequate staffing levels.
- Incomplete or infrequent patient observations.
- Information-related factors such as incomplete communication among caregivers and information being unavailable when needed.
- Care planning, such as assignment of the patient to an inappropriate unit or location.
Reducing Risk Factors
Organizations that experienced the suicides recommended the following risk reduction strategies:
- Revising suicide risk assessment/reassessment procedures (for example, using a standardized procedure).
- Updating the staffing model.
- Enhancing staff orientation/education regarding suicide risk factors.
- Updating policies and procedures for patient observation.
- Monitoring consistency of the implementation of observation procedures.
- Revising procedures for contraband detection and engaging family and friends in the process.
- Identifying and removing or replacing non-breakaway hardware.
- Weight testing all breakaway hardware.
- Redesigning, retrofitting or introducing security measures (for example, locking mechanisms, patient monitors and alarms).
- Revising information transfer procedures.
- Implementing education for family/friends regarding suicide risk factors.
Experts' Recommendations
John Oldham, M.D., director of the New York State Psychiatric Institute in New York City, emphasizes that good patient care is the first step in preventing inpatient suicides. Organizations also should examine their environment of care to make sure that patients do not have access to items that could be considered harmful to them.
Oldham recommends that facilities adopt the following practices:
- Make sure that items that can harm patients in the facility are addressed (for example, install appropriate shower heads, shower bars and closet bars that do not easily suggest such a use; do not leave doors open that should be closed; and do not give patients access to sharp objects and other potentially harmful items such as cleaning solvents).
- Institute professional practice guidelines that are helpful in administering appropriate medications and dosages and appropriate combinations of medications to treat conditions that contribute to the risk of suicide.
- Pay particular attention to patients who have multiple diagnoses that in combination can increase the risk of suicide (for example, a combination of depression and substance abuse).
- Institute policies about passes and privileges for patients that are considered a suicide risk (for example, exercise special caution when a patient has his/her first unaccompanied pass to an activity in the facility or a trip outside the facility).
William Tucker, M.D., director of the Bureau of Psychiatric Services in the New York State Office of Mental Health in New York City, says that organizations should assess the degree of suicidal risk on admission, with the intent to place those with the highest risk on constant observation. Staff members who provide any level of observation should inquire at least once per shift regarding suicidal intent, and more frequently if a positive response is obtained or suspicion is high.
"Avoid reliance on 'pacts' with patients that they will not act on suicidal impulses," Tucker explains. "Also, maintain a high level of suspicion if perturbation is present, or paradoxically, if symptoms lighten."