The Joint Commission (TJC) recently released its Sentinel Event Data through 2013. Suicides remain the fourth most frequently reviewed Sentinel Event for the second year in a row, with 90 reported last year. The reporting of most sentinel events to the Joint Commission is voluntary and represents only a small proportion of the actual events. Suicides were ahead of Falls and Medication Errors on this list as well as four other major categories.
There were 775 Root Cause Analyses of suicides studied by TJC from 2004 through 2013. Of those, “Assessment” was a root cause in 624 (80%) of the cases and the “Physical Environment” was a root cause in 329 (42%) of the cases studied.
This is consistent with the Department of Veterans Affairs study conducted in 2012 titled “Suicide Risk Factors and Risk Assessment Tools: A Systematic Review”. This was a very thorough evidence based study of all of the patient suicide assessment tools then being used in the entire VA hospital system. It concluded that none of the tools studied should be relied upon.
I posted a blog on this website on August 16th of last year regarding how even one-to-one observation is not always successful in preventing inpatient suicides and that other common steps taken for patients that are identified as at risk for suicide are even less successful. I recently received a comment on that blog that was a beautifully written explanation by a patient of why the typical questions and interventions do not work for people with Bipolar I diagnoses. The gist of this explanation was that once the decision was reached to commit suicide and how and when to proceed that the overwhelming feeling was “calm, almost peaceful”. In many of the suicides with which I am familiar (others have told me of similar observations) the clinical staff comment that they had no idea that the patient was actively having suicidal ideations immediately before the event occurred. This is not an indictment of the staff. It is a statement that we have yet to identify ways of identifying all of the patients who are on the verge of ending their own life.
For this reason and the fact that TJC reports that the physical environment is a contributing factor in over 42% of inpatient suicides, I continue to emphasize that behavioral healthcare facilities and their designers need to provide the full level of suicide resistance deemed necessary for each facility’s patient population in all patient rooms and bathrooms as well as identified appropriate levels in other portions of the unit where patients have less privacy or alone time. It is impartiive that we remove as many potential risks as possible from the patients' environment at the same time we are providing calming, relaxing spaces that will help them to be open to the treatment they will receive.