On February 24th TJC published Sentinel Event Alert 56 on Detecting and treating suicide ideation in all settings. Like all the Sentinel Event Alerts you will want to assign a team to review and analyze the information in the alert and to implement those recommendations that will help improve care in your organization. As with all alerts, there is no mandate to implement all the advice, but there is an expectation that the advice be considered, so be sure to document your team’s analysis and conclusions.
The importance of this alert is driven home by the continued high level of reporting in the sentinel event reporting program of suicide taking place in hospitals. TJC indicates he has received 1089 reports of suicide taking place in hospitals since the start of their voluntary reporting program, and this remains one of the more frequently reported sentinel events. A key root cause consistently reported is the assessment process either being delayed or inadequate at detecting the risk.
One aspect of your analysis is going to be the applicability of the safety goal requirement to your hospital and the applicability of this advice, entitled Suicide prevention in all settings.is prefaced by a note that states: “This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.” It is also applicable to organizations accredited under the BHC manual. This Sentinel Event Alert clearly looks for organizations to broaden their screening procedures to patients beyond just those who come for treatment of their behavioral health disorder, which will have significant implications in outpatient settings where staff working in that setting may not be licensed to conduct patient assessment.
One thing you will also want to do with this alert is to read it online directly. There are a large number of internet links to great tools and resources that you can link directly to online. Links are provided to several different screening tools and programmatic guidance developed by the VA and DOD on prevention of suicide.
In the Sentinel Event Alert there are 8 specific recommendations and some are broad in scope so you might want to assign subcommittees of a larger team to analyze some of the recommendations.
Suicide prevention is a national concern and, based on the number of sentinel events which continue to be reported from 24-hour care providers, demonstrates that we must do more to prevent suicides in our organizations. TJC mentions the frequency of its surveyors scoringwhich under emphasizes the actual number of suicide prevention-related findings since unaddressed environmental risks/issues are scored frequently under . We continue to see on mock surveys suicide screening tools being completed because it is mandated, but no process to analyze, quantify or take action on the results obtained. We also frequently see patients placed on q 15-minute observation because that is the minimum for a newly admitted patient, but no formal method to upgrade the level of supervision until later that day or the next day after the patient is seen by a psychiatrist. A last performance gap often seen is the physical environment and self identified defects which are slated for improvement in budget year 2017, 2018 or later, but no mitigation strategy is identified to keep patients safe until the environment is improved.
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