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One-to-one observation not always effective in preventing suicide

August 16, 2013
by James M. Hunt, AIA
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The final step in trying to keep a suicidal patient safe is often assigning a “sitter” to the patient.  This practice is often referred to as providing “one-to-one” observation.  While visiting a hospital in Maryland earlier this year, I was privileged to sit in on part of a Grand Rounds presentation by Dr. Jeffrey S. Janofsky, Associate Professor and Director of the Psychiatry and Law Program at Johns Hopkins.  Among the very interesting statistics he presented was one from a study that was published in the Journal of Clinical Psychiatry in  2003* that particularly got my attention. 

This study found:

-28% of patients committing suicide while inpatients had “contracted for safety”

-42% were on 15 minute checks

-20% were on 30 minute checks

-29% were not on regular checks

-9% of inpatient suicides occur while patients are on one-to-one observation.

How can this happen?  His response is that the “sitter” may be distracted, fall asleep, leave the room, be tricked by the patient into leaving him/her alone to go to the bathroom, etc. or the patient may render the “sitter” unconscious.

This information is very surprising to me.  So the question is how do we mitigate this risk?  The only suggestion I can offer is that the rest of the staff on the unit must not rely too heavily on the fact that the at-risk patient has a sitter and assume that no other intervention is needed.  Perhaps creating a policy where patients on one-to-one observation remain on regular 15 minute (or other) rounding checks and that the “sitters” be engaged frequently to see if they need a break or to help them stay alert even if the patient appears to be asleep.

I am curious if others have encountered this situation and if there are other ideas for mitigation.  If so, please comment on this post.

* Busch KA, et all: Clinical correlates of inpatient suicide. J. Clin Psychiatry 2003; 64:14



In addition to including 1:1 patients on routine 15 minute checks, our inpatient service limits the time that an individual staff member may sit on a 1:1 to 2 hours.
Staff are instructed that 1:1 means CONSTANT Observation, regardless of the patient activity. We train them how to explain to the patient,in delicate or embarassing situations the necessity of the supervision.


These sound like good practices that should help. Possibly one of the biggest issues is that other staff will think that the patient on one to one is taken care of and they do not need to be checked on during regular rounds.

The policies you mention should go a long way toward reducing the risks I mentioned. The remaining risk would be the patient physically overcoming the sitter. This can be a very real risk, especially with patients who have military or other martial arts training.

I am not a doctor, but I can tell you exactly why. I actually addressed this for a college psych course following the death of Amy Winehouse. People repeatedly joked about how everyone saw it coming or it was just a matter of time. The thing is that wasn't true. She was the healthiest she had been in years according to family and friends. She was active, social, and sober. She was also Bipolar just like me. What you find in Bipolar 1 suicide attempts is that we often conform to the rules of death about as well as we do in life. (being bluntly honest) My most serious suicide attempt was many years ago and a good example.(as with many of my close friends)You have to understand that my mind is also a jumble of chaotic emotions and thoughts and indecision. It was the clearest decision I have ever made. There was no self doubt. No second guessing, and having decided I was calm, almost peaceful. I did not leave a note or cry or consider what my funeral would be like or how people would be sorry. I wasn't sorry for myself or looking for someone to save me. With a myriad of stacking diagnoses, phobias, obsession, and fears, moments of clarity are not part of my normal mindset. I fed the horses, sat outside by the pond until the sedatives took hold, and went to bed. I am not sorry I lived, but it's important you understand the attraction. Sylvia Plath said,
I have done it again.
One year in every ten I manage it..

It's like a skip in a record, you see? You try to fill the space with anything... everything.. but you always come back to it. When you feel everything all the time, all you want is silence and numbness..

That's what makes it different for Bipolar. Your sense of self preservation should kick in. Their should be hesitation marks, but instead, you are decisive and your mind is clear. We won't fit your risk assessment, and it isn't an act you can assess for dishonesty. It's almost like being sane for the first time in your whole life... I hope that wasn't too dramatic, but being like me, I attracts similar people. I've lost a lot of people I cared for because people were looking for signs that were never going to come. With those cases, don't bother with your signs and questions. Bipolar people can't stand to be alone with themselves. That is the giveaway.

Thank you for this beautifully written explanation and insight into the thought process and state of mind of people suffering from bipolar disorder when planning suicide.

I am not a doctor either, I am an architect trying to design environments to help keep people safe. I have heard others say that people planning suicide become calm and peaceful after they have decided the how and when of the method they have chosen. This often gives staff and family members the sense that the risk has passed.

I agree with you (and the increasingly large pool of data) that the currently used suicide risk assessment tools and methods do not work with many people. This raises the question of what would help or what should others concerned about a persons well being look for?

Your last two sentences may be the key. "Bipolar people can't stand to be alone with themselves. That is the giveaway." Do you have any other suggestions of how the suicidal intentions of people suffering from bipolar disorder might be recognized and identified?

It is the key for other people, but the real problem is that you always work your way back around to it. Bipolar people tend to attract other Bipolar people, and the simple fact is, you might save a life in that moment, but from personal experience, repeating personal experience, it's more like a temporary reprieve. Two years ago, I spent an evening with my first love from my youth while he was overdosing on the phone with me from several states away. I'm going to be honest here. He was the one I always believed would make it. He was just so talented and infectious and beautiful. My sister called the morning of my birthday. He had shot himself that morning in the bathroom while his wife and baby slept in the adjoining room. Of course, I have to admit that there was no miscommunication this time. He didn't want to be saved. I can only assume he was in terrible pain. What I learned, and I learned it through years of trial and error and self destruction... You have to have something to hold on to. You have to get up, and acknowledge it every morning and be angry at it for making you live or be thankful for it giving you a reason.If you miss a day, it sneaks up on you. If you don't find a way to ground yourself, you get swept up in the undertow.. After all, that's easier than fighting against it. I'm also really lucky. I have a husband who I am completely honest with. If I tell him I feel suicidal, he doesn't see it as a reflection on him, and he doesn't judge me. He doesn't preach. He takes the night off, and we watch movies from the living room floor while eating appetizers... He doesn't tell me why I should keep coming. He gives me a reason.

Jim Hunt

Behavioral Healthcare Design Consultant

Jim Hunt

James M. Hunt, AIA, is a practicing architect and facility management professional with over 40...

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