1. Adamski, Pat RN, MS, MBA

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The Joint Commission's Sentinel Event Statistics reveal that from January 1995 through June 2006, 13.1% of reported events were patient suicides. This makes it the leading type of sentinel event reported and emphasizes the need to reduce its incidence. In late 1998, The Joint Commission issued a Sentinel Event Alert on inpatient suicides, calling to action provision of information regarding the root causes that were identified, along with recommendations for prevention.


Adopted at the beginning of this year, National Patient Safety Goal (NPSG) 15A requires organizations to identify patients or clients at risk for suicide. Here are answers to some frequently asked questions regarding this new goal.




Q Does NPSG 15A require that we conduct a risk assessment for all admitted patients?


A The goal is applicable to organizations surveyed under the behavioral health and hospital standards. This includes psychiatric hospitals and patients treated for emotional or behavioral disorders in general hospitals. If a patient presents with a primary diagnosis of a medical nature and a secondary diagnosis that's behavioral in nature, the goal doesn't apply.



Q What if a patient presents to the ED for treatment of injuries sustained in a motor vehicle accident while attempting suicide? Would a risk assessment need to be done because the primary diagnosis is injury related?


A By virtue of the suicide attempt, the patient has self-identified as a suicide risk. A risk assessment isn't necessary. Your efforts should focus on treating the injuries and addressing the patient's emotional condition, including providing a safe environment.



Q Is an environmental risk assessment required under this goal?


A The need for a proactive risk assessment of buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and others actually falls under standard EC.1.10, "The hospital manages safety risks," and has been a requirement for some time. Standard EC.8.10 also states, "The hospital establishes and maintains an appropriate environment." Evaluating your organization's environment for potential safety issues is part of a comprehensive proactive risk assessment. Implementing corrective actions to mitigate those issues is also expected.



Q Does this goal also apply to outpatients?


A This requirement applies to all services surveyed under the hospital and behavioral healthcare standards, and includes the ED, hospital-based outpatient services, and clinics.



Q What needs to be included in the suicide assessment?


A Implementation Expectation No. 1 states, "The risk assessment includes identification of specific factors and features that may increase or decrease risk for suicide." Your organization can determine the details of the risk assessment process. Performing a screening first and then a comprehensive assessment, when needed, is an acceptable approach.



Q One of the requirements states that we need to provide information for crisis situations to patients and their families. Do we need to provide this to everyone who's assessed?


A No, you would only need to provide this information to those patients identified as being "at risk" and their families. Information could include phone numbers for crisis hotlines, services, and resources. These can be services and resources in your own organization or those located in surrounding communities.