by Twila Loudder, MS, RN, CPHQ
Vizient Accreditation Advisor

Tragically, suicide is a serious public health problem that impacts millions of lives each year. The 2021 Suicide Call to Action report from the National Action Alliance for Suicide Prevention reported suicides increased by 32% from 1999 to 2019.

The Centers for Medicare & Medicaid Services’ (CMS) public list of citations revealed nearly 150 citations were issued to organizations for suicide prevention related findings. Almost two-thirds resulted in CMS Immediate Jeopardy (IJ) findings. The most common themes focused on a lack of suicide risk screening and assessments, not providing safe environments, and failure to monitor patients adequately. Behavioral health and emergency departments were the health care settings most often cited.

According to The Joint Commission’s Sentinel Event Data Summary, in 2021, 1,197 sentinel events were reviewed and 79 (almost 7%) were related to suicide. The Joint Commission’s (TJC) 2021 survey data published in March 2021 highlighted that for hospitals, three of the top 10 survey findings were related to the standard elements of performance (EPs) 1, 4 and 5 of the National Patient Safety Goal (NPSG.15.01.01)—Reduce the Risk of Suicide. EP 1 related to ligature risks was the number two most cited survey finding. In behavioral health (BH) hospitals, five EPs (1, 2, 3, 4 and 5) at NPSG.15.01.01 accounted for the top five findings. These trends correlate closely to the CMS findings.

Patient safety in health care settings is a core responsibility, and suicide risk and prevention are widely recognized as critical components of patient safety programs. Compliance to TJC and CMS standards are vital in reducing the risk of patient suicide. Here are some tips to maximize patient safety.

Policy requirements 

The organizational suicide risk and prevention policy must address key components to meet all requirements. Implementing a sound policy guides staff in a clear and consistent manner. Key topics include:

Suicide screening process—Describe the screening process using a validated tool. You must screen patients 12 years old and older presenting with behavioral issues upon triage or admission as a primary concern. The tool should define a positive screen. 

Patient who screens positive for suicide—Describe the evidence-based process you will use for patients who have screened positive for suicide risk. Correlate level of risk with the action needed for the patient. A patient identified as a high risk must be placed on 1:1 observation with an individual that has verified competencies for the responsibility of monitoring the patient for safety. The overall level of risk must be documented. The suicide risk assessment can be completed by a designated qualified individual, such as a psychiatrist, behavioral health social worker or a properly trained nurse. Describe when suicide risk reassessments must be completed. A good target is once every shift.

Initiating suicide precautions—Describe what suicide precautions are, who can initiate, how they are ordered and how and who documents the precautions put in place. Complete the section by defining when and how precautions are removed and by whom. 

Safety monitoring requirements—A crucial component in suicide risk prevention is making sure the patient is safe from harm. You must describe the monitoring and the monitoring frequency. How is it documented? Who documents it? Be sure to include safety observer/monitor documentation and nursing documentation requirements.

Constant observer requirements—Constant observers are necessary to mitigate environmental risks, incorporating the environmental risk assessment in their workflow raises staff awareness to help patients stay safe.

Competency and training of staff—Training and competency requirements for the screen and assessment/reassessment process, suicide precautions and documentation requirements should be addressed. Be sure to have documented competency of anyone who will perform suicide 1:1 observation.

NPSG.15.01.01 Reduce the Risk of Suicide Standard Compliance 

There are different requirements for the three EPs identified in the TJC survey trends. TJC has information in their Patient Safety Topics on Suicide Prevention that addresses suicide risk and prevention that provides several resources to ensure compliance. Additional tips for compliance are discussed below.

EP 1 Environmental Risk—Behavioral settings, including dedicated behavioral health rooms in the emergency department must conduct an environmental risk assessment (ERA) to identify and minimize features in the environment that could be used to attempt suicide. The ERA should be completed regularly and anytime unit or room modifications are completed. Some organizations accomplish this by conducting an annual ERA or a perpetual ERA.

The perpetual ERA is used by the patient safety team to round, identify new risks and follow up on previously identified risks. A frequent finding is the omission of self-harm risks in the environment when using the ERA. This EP applies to dedicated units and non-dedicated areas where suicide risk patients are seen or treated. The emergency department is one example. An emergency department without dedicated behavioral health rooms/units can use checklists to facilitate removal of self-harm items. For patients that are high risk the required mitigation is 1:1 direct monitoring by a competent observer, which is one staff member continuously monitoring one patient. Video monitoring cannot replace this requirement. 

EP 4 Document patients’ overall risk for suicide and plan to mitigate the risk—Problems arise when all clinicians who might come in contact with a patient are not aware of the patients’ risk level for suicide and the plans to mitigate those risks. A common pitfall is not assessing and documenting the risk in the medical record. Using the screening results as the overall risk without performing a full suicide risk assessment is also a frequent pitfall.

EP 5 Follow policies and procedures—Ensure your policies and procedures include how to care for patients at risk for suicide, including what education and training should be completed and when and by whom. The policies should also include when to perform reassessments and how to monitor patients. Don’t forget to include what, when and how to document the reassessments and monitoring.

Keeping patients safe in the health care setting can be complex and requires vigilance. Remembering four key strategies will help you identify and implement appropriate safeguards to ensure every patient is safe. The key strategies are:

  1. Develop sound, comprehensive policies then educate your staff 
  2. Evaluate all environments where patients at risk for suicide are cared for to identify and mitigate every risk for self-harm
  3. Ensure patients who are at risk for suicide are identified; early and accurately
  4. Complete a thorough risk assessment and mitigate those risks, including 1:1 observation

About the author: Twila Loudder provides accreditation/regulatory consulting and coaching to healthcare organizations. She is an experienced acute care nurse with over 30 years of experience in nursing, quality and risk management.

Published: April 19, 2022