The Joint Commission has issued a new Sentinel Event Alert on preventing suicide. It is really an update to a previous Sentinel Event Alert on preventing suicide (TJC 1998). The focus of the new alert is on units other than behavioral health units, i.e. medical/surgical units and the emergency department.
They provide statistics about suicide on various units, places the suicides take place, and means used. They point out that there are 2 types of patients who commit suicide on med/surg units: (1) those admitted after a suicide attempt and (2) those with no known psychiatric disorder or know suicide intent. They detail the many risk factors for suicide plus the potential warning signs. Suicide on med/surg units also tends to occur earlier after admission than those occurring on behavioral health units.
They discuss many of the environmental items, usually not available on psychiatric units but readily available on med/surg units, that may be used in suicides. These include items such as bell cords, sheets, restraint belts, various types of tubing, bandages, etc.
But key contributing factors are lack of screening, failure to identify risk or recognize warning signs, lack of appropriate training, poor communication, and lack of appropriate staffing for proper observation.
They make a number of recommendations regarding screening for depression and suicide risk (both inpatient and emergency department) and watching for behaviors that are potential warning signs of impending suicide attempts. They then offer tips about engaging the patient and family or others capable of providing peer support. And they stress the importance of communication at all levels of care.
We have previously done Patient Safety Tips of the Week on January 6, 2009 “Preventing Inpatient Suicides” and February 9, 2010 “More on Preventing Inpatient Suicides”. We encourage you to read those columns since they have many practical considerations. You need to be especially cognizant of the risks when patients go elsewhere in your facility. An AHRQ WebM&M Case & Commentary several years ago noted a suicide attempt occurred in a bathroom in the radiology suite. We wonder how many hospitals would have inspected that bathroom for potential suicide risk. We’ve done that in several hospitals and uniformly found that not only do those bathrooms have numerous “loopable” items that could be used for hanging but also that they can be locked from the inside and there is typically no one readily available with a key to get in. In fact, that is one of the items we added to our patient safety scavenger hunt list (see our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt”). Bathrooms on non-psychiatric floors may be especially problem prone. Not only are they seldom assessed for tools and implements that could be used for suicide, but some also allow the door to be locked from the inside. So observation protocols for potentially suicidal patients on such units should ensure that doors are not locked (or, if they can be locked, that the “observer” has keys to access the bathroom). Having observers of the same gender as the patient also is recommended.
You also need to consider areas you often do not consider accessible. We heard of a case recently where locked doors automatically opened when the fire alarm went off and a patient then got access to a rooftop. So during your environmental safety rounds you need to say to yourself “what could happen if those doors were to become unlocked?”.
Communication to all parties is particularly important during transports within the hospital (such as going to the radiology suite). We’ve talked about the “Ticket to Ride” communication tool for hospital transports. That useful tool needs to also be used to properly prepare for potentially suicidal patients.
Suicide risk assessments are often incomplete or not done and the 1998 Joint Commission alert especially noted a dearth of suicide reassessments. Sound familiar? How often have we noted that other key assessments in healthcare, such as fall risk or DVT risk assessment, are done on admission but are not repeated even though clinical circumstances have changed during the hospital course? Another issue is that even though the reason for admission may have been related to a suicide attempt, the patient on admission may be unable to cooperate with a suicide risk assessment (eg. the patient may be comatose or obtunded because of a drug overdose). Sometimes many days pass where the patient physically would have been incapable of another suicide attempt but, ironically, as they begin to improve medically the suicide risk reappears.
Several articles have noted that the “sitters” commonly utilized to monitor the potentially suicidal patient on the non-psychiatric unit are often not specifically trained in assessment of the environment or management of the suicidal patient. The AHRQ article noted above has a good discussion on this.
Our February 9, 2010 Patient Safety Tip of the Week “More on Preventing Inpatient Suicides” has some good descriptions of the types of patients on med/surg units prone to suicides. Especially vulnerable are those with delirium or dementia. That column also discusses the availability of several great tool kits for education and management of suicide risk.
Since it is very difficult to predict suicides, careful attention to environmental factors that could facilitate suicide is critical. Appropriate assessment and reassessment for suicide risk are important. Similarly, for those patients identified as at-risk for suicide, it is essential that appropriate monitoring with appropriately trained staff be used. Transitions of care are especially vulnerable and suicide risk should be considered in all handoffs and other communications.
Suicide on one of your inpatient services, whether psychiatric or med/surg, is a devastating event for families, your other patients, your staff, your community, and your reputation. You need to get a better understanding of your vulnerabilities and take action to mitigate the risks of potentially avoidable events.
The Joint Commission. A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department. Sentinel Event Alert 2010; 46: 1-5 November 17, 2010
The Joint Commission. Inpatient Suicides: Recommendations for Prevention. Sentinel Event Alert 1998; 7: 1-2 November 6, 1998
Gibson J, Taylor DH. AHRQ Web M&M Case & Commentary “The Dangerous Detour.” June 2003