A suicide risk assessment is one of the most important processes in providing safe care of patients at risk for harm. During the suicide risk assessment, patients are asked questions about suicidal thoughts and behaviors, plans, risk factors, and protective factors. Clinicians analyze this data in determining the degree of risk and corresponding actions to mitigate the risk. While suicide risk assessments and plans of care can be relatively straightforward, challenges and opportunities frequently present in maintaining consistently safe environments given this risk.
The Joint Commission’s National Patient Safety Goal (NPSG) 15 focuses on reducing the risk for suicide. The last update to NPSG 15 was effective July 1, 2019, with new and revised elements of performance. These elements address a compendium of environmental and clinical areas for suicide risk reduction. Depending on the type of healthcare setting, an environmental assessment is required to evaluate risks for harm, such as the presence of ligature or sharp items that need to be managed. A validated suicide ideation screening tool and evidence-based assessment process, as specified for the setting, helps to discern which patients require higher levels of monitoring and other safety considerations. Along with clinical documentation, the elements address policies and procedures for training, competency, reassessment, monitoring, and discharge care.
In the high demand, busy healthcare environments we experience today, maintaining continuous compliance can be challenging. To assist, leaders can use a variety of methods to promote situational awareness of suicide risk, consistency in following policies and procedures, and high reliability of care.
Observations from the Field and Key Considerations
Environmental Risk Assessment
An environmental risk assessment is intended to find safety issues that can lead to a patient suicide or harm. Safety issues include ligature points, access to sharp items, and everyday articles like plastic bags that could be used for suffocation. A multidisciplinary plan is needed to mitigate the identified risks including the installation of ligature-resistant hardware, locking doors and cabinets, removal of plastic bags in high-risk areas, and increased patient observations such as one-to-one monitoring. An environmental risk assessment needs to be a living, breathing document that is reassessed at regular intervals to capture changes in the physical environment. Key considerations include:
- In assessing the environment, thoroughly examine all areas of the healthcare setting such as waiting rooms as posing potential risks. Consider how tubing, call bell cords, exposed pipes, patient belongings, and supplies can be used for harm.
- If cameras are used for monitoring, look for any blind spots such as corners or poorly lit areas in which the view of the patient may be obscured. Consider the effectiveness of this type of monitoring when the unit and patient rooms are darkened for sleep purposes.
- When renovations or other physical environmental changes occur, reassess the environment to determine if new risks are present or modifications to the mitigation plan are needed. Did renovations cause sharp edges or increase ligature risk?
- Ensure that all staff are trained on the mitigation plan and their specific role in reducing suicide risk.
- Document findings and actions taken for review and discussion in committee and staff meetings.
- Assess mitigation strategies for effectiveness and revise accordingly.
Conducting the Suicide Screening and Assessment
As noted in The Joint Commission NPSG 15, a validated screening tool for patients aged 12 and older and an evidence-based process for a suicide assessment are required. Suicide screening and assessment is a thoughtful process that calls for focus, attention to detail, and compassion. Key considerations include:
- Ensure full use of the validated screening tool as designed. Utilizing a sub-set or changing the questions invalidates the tool.
- Given the high-risk nature of the screening and assessment, conduct the evaluation in an area as quiet and as free of distractions as possible while maintaining a personal position of safety.
- Incorporate clinical judgment when sensing risk of harm such as a patient denying suicidal ideation after a serious event.
- Conduct tracer activities proactively on the screening and assessment process. Look for areas in which communication gaps can occur in relaying critical information on high-risk patients, resulting in a sentinel event.
- Perform documentation reviews on the scoring of suicide screenings and assessments for accuracy, completeness, and follow-up actions. Provide prompt feedback and support to staff on the findings.
Leadership rounding is a great opportunity to assess and support high risk processes like suicide assessments and patient monitoring. During leadership rounds, supervisors and other leaders can observe patient care, ask staff about concerns, and needs, find problems when they are small and easy to manage, and communicate information. Key considerations include:
- Leadership rounds can be an effective means to follow-up on environmental risk assessments and to ask staff about mitigation strategies.
- Given the potential changes that may occur in patient care areas, leadership rounds can include a check for new ligature risks and unapproved items such as contraband.
- If opportunities are noted, just in time training can be used to reinforce requirements on important areas such as one-to-one monitoring. Ask how information on suicide risk is handed off between staff members and during shift change. Additionally, just in time training is essential when staff are observed not providing their undivided attention to the patient when providing one-to-one monitoring.
- Leaders can use the opportunity to see the environment as a patient may. Are there items that could be used to self-harm? Are there additional ways to provide safety to the patient? How can patients be best engaged in staying safe?
Root Cause Analysis for Incidents and Near Misses
If an actual incident or near miss related to suicide screening and assessment occurs, a root cause analysis is essential in detecting process issues that can be addressed, and in proactively preventing future harm. A root cause analysis can also reveal effective actions that can be celebrated along with insights to be shared with teams. Key considerations include:
- Incorporate root causes into process improvement projects.
- Emphasize the purpose of a root cause analysis in addressing processes, not individual human errors.
- Defer to external and internal experts in any redesign of processes and systems. Remember that internal experts are frequently those who directly provide care to patients and are uniquely knowledgeable on what works well and what issues exist.
Healthcare organizations can encounter significant suicide risks within their patient populations. Reducing suicide risk requires consistent attention to detail, multidisciplinary collaboration, and ongoing vigilance. By employing a variety of effective methods to reduce suicide risk, leaders can both mitigate these risks and reinforce a thriving culture of safety through their efforts.
The Joint Commission: Suicide Prevention Portal. https://www.jointcommission.org/resources/patient-safety-topics/suicide-prevention/