What’s New in the Patient Safety World

July 2012

VA Checklist Reduces Suicide Risk



We’ve discussed the risk of inpatient suicide in multiple columns, both on mental health units and on med/surg units or ICU’s (see list of columns at the end of today’s column).


And we’ve discussed some of the tools available to help identify risk factors for inpatient suicide that might be mitigated or avoided. In our January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides” we noted that the VA had developed a mental health environment-of-care checklist (MHEOCC). That checklist is available online on the VA Patient safety website. In our February 9, 2010 Patient Safety Tip of the Week “More on Preventing Inpatient Suicides” we noted an article on use of that checklist (Mills 2010). They implemented the checklist at 113 VA facilities and identified over 7000 potential hazards. A real value of the checklist is that it not only itemizes hazards but it is actually weighted by potential severity of the risk of each hazard (on a scale of 1 to 5). The commonest hazards they identified were anchor points that could be used for hanging. The second most common hazards were materials that could be used as a weapon against staff or other patients. Third most common were security issues that raised the risk for elopement. They also looked at the location of hazards and noted that bathrooms and bedrooms were a frequent site for hazards. Those two rooms obviously are potentially at greater risk for suicide because of patient isolation. Their discussion of the elopement risk is also quite good. They note certain areas (eg. physical therapy rooms, art rooms, group rooms, utility rooms, etc.) where it is important to identify that patients will not be left unsupervised and they discuss safeguards such as self-closing and locking doors. Though they discuss the use of video camera monitoring, they point out that it is unreasonable to expect staff to reliably monitor video screens for long periods of time. They also point out that, though they found materials for suffocation or poisoning less often, the high potential for lethality of those materials merits special attention. This would include items like plastic liners in trash cans and cleaning products. Those are especially important to look for on units other than psychiatric units. Overall, this is a very good checklist for conducting environmental rounds with a purpose of reducing potential risk for suicides.


Now a new study demonstrates that use of the MHEOCC significantly reduced the risk of inpatient suicide (Watts 2012). They compared suicide rates in VA hospitals before implementation of the MHEOCC with those after implementation and found a substantial reduction in the rate (from 2.64 suicides per 100,000 inpatient mental health admissions to 0.87 per 100,000). This translated to a 62% reduction in suicide rates at VA hospitals, compared to an estimated 21% reduction in non-VA hospitals over the same timeframe. The most frequently identified hazards were anchor points in bathrooms or closets. They suggest use of shower heads that do not provide anchor points and use of breakaway clothing hooks. They also note that the 3 suicides that occurred in the VA system after implementation the hazard could have been identified and abated through use of the MHEOCC.


So the MHEOCC is a very good tool for identifying and abating environmental factors that might facilitate inpatient suicide. Don’t forget that patients admitted to mental health units may also go to other sites in the hospital (eg. radiology). So make sure that you also assess the environmental risk in places like bathrooms in radiology.



Some of our prior columns on preventing hospital suicides:


·        January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides

·        February 9, 2010 Patient Safety Tip of the Week “More on Preventing Inpatient Suicides

·        March 16, 2010 Patient Safety Tip of the Week A Patient Safety Scavenger Hunt

·        December 2010 What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units

·        September 27, 2011 Patient Safety Tip of the Week “The Canadian Suicide Risk Assessment Guide

·        December 2011 What’s New in the Patient Safety World column “Columbia Suicide Severity Rating Scale







Mental Health Environment of Care Checklist




Mills PD, Watts BV, Miller S, Kemp J, Knox K. DeRosier JM, Bagian JP.

A Checklist to Identify Inpatient Suicide Hazards in Veterans Affairs Hospitals
Joint Commission Journal on Quality and Patient Safety. Volume 36, Number 2, February 2010 pp. 87-93(7)



Watts BV, Young-Xu Y, Mills PD, et al. Examination of the Effectiveness of the Mental Health Environment of Care Checklist in Reducing Suicide on Inpatient Mental Health Units. Arch Gen Psychiatry. 2012; 69(6): 588-592















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