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Patient Safety Tip of the Week
Hospital
Suicides
Suicide that occurs in a hospital is
obviously devastating for the family and loved ones of the patient who commits
suicide. But it is also devastating for hospital staff and the community in
general. Weve done many columns on suicide that
occurs either in behavioral health facilities or in general hospitals. But we
were surprised to see that we had not done one in almost 4 years. A recent
Medscape article (Lavaud
2025) reminded us that this
might be a good time to again discuss the subject.
.
Stephanie Lavaud discussed a presentation by
French psychiatrist Pierre-Emmanuel Michels at a psychiatry conference held
recently in Paris (Lavaud
2025). (Interestingly,
Lavaud used several editorial tools, including AI, to translate the article
from the French edition of Medscape.) Michels noted that epidemiological
studies from the United States and Sweden found that the suicide rate in
psychiatric hospitals is 50-72 times higher than that in the general
population. The studies also found a high suicide risk at the start of
hospitalization (77%), and an extremely high suicide rate immediately after
discharge, particularly within the first week post-discharge. 73% of suicides
occurred in psychiatric units. Hanging was the most common method (70%) in all
settings.
Nearly one-third of deaths by suicide occur
while the patient is on 15-minute observations (Mills
2008). A study of suicide
in patients admitted to psychiatric hospitals in Sweden (Lindberg
2024) found that 17% of
patient who committed suicide were on 15-minute checks and one-third were on
agreed leave at the time of the suicide.
Michels noted identified risk factors for
suicide include a family history of suicide, previous suicide attempts or
self-harm, despair, guilt, and depression. The risk is significantly higher
among individuals who express suicidal thoughts and the odds are 2.35 times
greater for those with mood disorders (Hubers
2018).
Michels analyzed almost 800 cases of
hospital suicide and identified five main contributing factors:
1.
Inadequate security unsafe rooms or furniture
2.
Communication failures within and between hospitals
and with families
3.
Staff-related issues include insufficient training and
excessive workload
4.
Service organization lack of clear suicide risk
assessment protocols, limited psychiatric referral access, and staff shortages
5.
Patient-related factors refusal of care, social
isolation
Risks in the emergency department are a
little different. A study of 184 self-harm incidents involving 118 unique
patients (Lawrence
2022) found suicidal intent
was present in only a minority of incidents. Other contributing factors
included psychosis, intoxication, aggression, managing distress, communication,
and manipulation. A wide variety of self-harm methods were used. In the
emergency department, patients often do not indicate suicidal ideation.
Therefore, it is important to restrict access to lethal means in the ED.
Weve discussed the
VAs Mental
Health Environment of Care Checklist (MHEOCC) in many
columns (most recently in our January 29, 2019 National
Patient Safety Goal for Suicide Prevention).
Weve also previously mentioned 2 publications (Watts
2016, Mills
2016) showing sustained results from implementation of
the Mental Health Environment of Care Checklist (MHEOCC). The checklist and
program became mandated at all VA hospitals in 2007. Inpatient suicide rates in
VA hospitals dropped from 4.2 per 100,000 admissions to 0.74 per 100,000
admissions from 2000 to 2015. The reduction in suicides coincided with introduction of the MHEOCC and has been sustained since
implementation in 2007. Those authors stress that the physical changes brought
about by the MHEOCC likely have a bigger impact on inpatient suicide reduction
than the numerous other interventions used.
Since hanging is typically the most common
mode of suicide in hospitals, we need to make sure the environment does not
contain structures or items to which ligatures might be attached. While
behavioral health units focus on using ligature-resistant hardware, other parts
of hospitals do not. We can almost always find a potential means for hanging
oneself in bathrooms in radiology suites or emergency departments. Hence, we
emphasize that Ticket to Ride checklists for intrahospital transport have a
section for considering patients who might be at risk for suicide.
Suicides in general hospital units often
occur because rooms do not meet the MHEOCC standards and because staff
observing patients are often not adequately trained for that task. See our columns
below on falls or jumps from hospital windows for more details.
Some
of our prior columns on preventing hospital suicides:
·
January 6, 2009 Preventing
Inpatient Suicides
·
February 9, 2010 More
on Preventing Inpatient Suicides
·
March
16, 2010 A Patient Safety Scavenger Hunt
·
December 2010 Joint
Commission Sentinel Event Alert on Suicide Risk Outside Psych Units
·
September 27, 2011 The
Canadian Suicide Risk Assessment Guide
·
December 2011 Columbia
Suicide Severity Rating Scale
·
July
2012 VA Checklist Reduces Suicide Risk
·
August
2013 Suicide Attempts on Med/Surg Units
·
August
25, 2015 Checklist for Intrahospital Transport
·
October
6, 2015 Suicide and Other Violent Inpatient Deaths
·
March
2016 TJC
Sentinel Event Alert on Preventing Suicide
·
April
12, 2016 Falls
from Hospital Windows
·
February
14, 2017 Yet
More Jumps from Hospital Windows
·
August
29, 2017 Suicide
in the Bathroom
·
December
12, 2017 Joint
Commission on Suicide Prevention
·
July 10,
2018 Another
Jump from a Hospital Window
·
September
18, 2018 More
on Hospital Suicides
·
January
22, 2019 Wandering
Patients
·
January
29, 2019 National
Patient Safety Goal for Suicide Prevention
·
July 30,
2019 Lessons
from Hospital Suicide Attempts
·
September
3, 2019 Lessons from an Inpatient
Suicide
·
August
11, 2020 Above-Door Alarms to Prevent
Suicides
·
September
22, 2020 VA RCAs: Suicide Risks Vary
by Site
·
February
2, 2021 MGH Protocols Reduce Risk of
Self-Harm in ED
·
June 22,
2021 Remotely Monitoring Suicidal
Patients in Non-Behavioral Health Areas
References:
Lavaud S. Patient Suicide in Hospitals:
Whats Behind the High Numbers. Medscape Medical News 2025; March 24, 2025
Mills PD, DeRosier
JM, Ballot BA, et al. Inpatient suicide and suicide attempts in Veterans
Affairs hospitals. Jt Comm J Qual Patient Saf 2008; 34(8):
482-488
https://www.sciencedirect.com/science/article/abs/pii/S1553725008340616?via%3Dihub
Lindberg M, Sunnqvist
C, Wangel AM, et al. Inpatient Suicides in Swedish Psychiatric Settings A
Retrospective Exploratory Study from a Nursing Perspective. Issues in Mental
Health Nursing 2024; 45(12), 1312-1318
https://www.tandfonline.com/doi/full/10.1080/01612840.2024.2405841#abstract
Hubers AAM, Moaddine
S, Peersmann SHM, et al. Suicidal ideation and
subsequent completed suicide in both psychiatric and non-psychiatric
populations: a meta-analysis. Epidemiol Psychiatr Sci
2018; 27(2): 186-198
https://pmc.ncbi.nlm.nih.gov/articles/PMC6998965/
Lawrence RE, Fuchs B, Krumheuer
A, et al. Self-harm During Visits to the Emergency Department: A Qualitative
Content Analysis. Journal of the Academy of Consultation-Liaison Psychiatry
2022; 63(3): 225-233
https://www.sciencedirect.com/science/article/abs/pii/S2667296021001828?via%3Dihub
Mental Health Environment of Care Checklist
(VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD.
Sustained Effectiveness of the Mental Health Environment of Care Checklist to
Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead
of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health
Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA.
TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September
2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
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