What can we learn from the inpatient suicide incidences? The September issue of Perspectives summarized an article published in the Joint Commission Journal on Quality and Safety.
Inpatient Suicide Incidence And Methods
It describes the incidence and methods used by patients who commit suicide in hospitals. You can read the entire article here.
They estimate that there are between 49-65 inpatient suicides each year. And, hanging is the cause of 70% of those deaths thus, the very intense focus on ligature hazards. They also identified the locations for these suicides. Half occur in the bathroom, another third in the bedroom, 4% in a closet, 4% in a shower and 8% in some other location.
It is easy to understand why the Joint Commission’s focus is on the bedrooms and bathrooms. In fact, we continue to see this issue on both mock and actual Joint Commission survey reports:
- Unrecognized ligature fixation points in psychiatric bedrooms and bathrooms
Either they didn’t remove the fixation point or identify it in a risk assessment. Even when identifying ligature risks, in the environment, in a risk assessment, direct care givers are not always apprised of them. As a result, they don’t realize there are any mitigation steps to put in place.
Plans For Changing The Existing National Patient Safety Goal?
This Perspectives article also mentions very general plans to change the existing National Patient Safety Goal 15.01.01. But, it doesn’t contain the specific new language. Here is the one topic they will address. The “documentation of patient’s overall level of risk for suicide and the plan to mitigate the risk for suicide.”
This is a great point for consideration. We do see suicide screenings taking place in the ED, on the psychiatric floor at admission and by staff members periodically. But, it is challenging to identify conclusions drawn from these screening processes. Defining the mitigation strategy or level of precautions placed as an end result is often very difficult. Plus, the actual suicide risk assessment, the conclusion from that assessment and the actions taken are often scattered in different parts of the chart if present at all.
So stay tuned for more on this soon.
Do you need assistance interpreting and implementing these or other Joint Commission guidelines? Patton Healthcare Consulting provides Joint Commission Compliance Assistance and a full range of pre-survey and post survey services to healthcare organizations. Contact our office at 888-742-4621, via email or through our website contact page to schedule a discussion of your needs and learn more about our compliance and readiness expertise.