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Patient Safety in Behavioral Health

According to the National Alliance on Mental Illness (NAMI), 1 in 5 adults experience mental illness and over 20 million adults have substance abuse disorder.  Additionally, suicide is the 10th leading cause of death in this country and suicide either in a healthcare setting or in the immediate post-care time period is among the most frequently reported/reviewed Sentinel Events by The Joint Commission.

As healthcare organizations seek to provide a safe environment and care for their patients, here are some considerations:

The Joint Commission is prompting organizations to consider safety in the psychiatric setting through enhanced survey focus on matters related to risks of suicide, self-harm and access to ligature opportunities.  In the March 1 edition of Joint Commission Online, new focus during survey and in the post-survey process is reviewed.

Organizations are encouraged to conduct environmental risk assessments wherever psychiatric patients are cared for and treated.  (Don’t forget emergency departments!)  Through that risk assessment process, prioritize risks, determine solutions, allocate resources and identify mitigation strategies until risks are eliminated.  Document those processes and get involvement through the appropriate committee structure.

Regularly evaluate processes for suicide assessment in patients in various settings.  When educating staff, share suicide statistics, lessons learned from literature or actual events and case studies to raise awareness and sensitivity to this population.

The survey process for evaluating suicide risks and concerns will be more intense and findings related to the risk of ligature or other self-harm will be scored as a higher risk on TJC’s SAFER MatrixTM.

Healthcare organizations that continually assess, prioritize and address risks throughout the organization demonstrate their commitment to patient safety and their progress as high reliability organizations.

Look to future editions of C&A eNews for more information, tools and resources on this topic.

Accessed 3/14/2017:



Joint Commission Online, March 1, 2017

Kerrie Bellisario

Author Kerrie Bellisario

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