When a person enters a psychiatric hospital or mental health treatment facility, there is an expectation of safety. Inpatient mental health facilities are designed to provide a safe and secure environment for intensive treatment including observation, diagnosis, individual and group psychotherapy and medication management. The overall plan of care is often a detailed coordinated effort between the individual, the family, the inpatient treatment team, and outpatient service providers. But when an inpatient suicide takes place in a mental health treatment facility, vulnerabilities of the facility must be carefully reviewed and addressed to help reduce and prevent the occurrence.
In Knoll’s article, the author closely examined the cause of inpatient suicide. Knoll reported the most commonly reported incident to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) between 1995 and 2005 was inpatient suicide. According to JCAHO, the greatest clinical root cause of inpatient suicide is a failure in clinical assessment. Risk was not adequately assessed in about 60% of suicides.
In psychiatric hospitals, the most frequent method of suicide is hanging, and 75% of inpatient suicides occur in the patient’s bathroom, bedroom, or closet. A problem that commonly arises in sentinel event reports, peer reviews, and malpractice litigation involves inadequate monitoring and protection of new patients with moderate or high suicide risk. The failure to conduct an adequate suicide risk assessment, when necessary, deprives the psychiatrist and hospital staff of the ability to use reasonable professional judgment in determining the proper safety precautions required for the patient.
The most common root causes of suicides on medical units include: (1) problems with communication of suicidal risk; (2) the need for staff education on suicide assessment and treatment; and (3) the need for improved suicide assessment. Knoll states that staff should exercise caution when utilizing 15-minute checks with seriously suicidal patients who has been assessed as high risk or uncertain risk. He further states inpatients can and do commit suicide while on 15-minute checks. In a study of 76 patients who committed suicide while in the hospital or immediately after discharge, 78% denied suicidal ideation and 51% were on 15-minute checks.
According to Knoll, suicides in busy inpatient facilities have occurred when there is a breakdown of the therapeutic alliance, resulting in malignant staff attitudes. It is believed that staff may lose objectivity and begin to view patients as manipulative, provocative, unreasonable, over-dependent, or feigning. Therefore, the risk of suicide may increase when the therapeutic alliance breaks down and when patients have recurrent relapses and are resistance to treatment. The two highest-risk times for suicide are the first week after admission to an inpatient mental treatment facility and shortly after discharge. Knoll reports generic group therapy may do little, and paradoxically may increase risk by introducing psychological conflicts and issues prematurely. Thus, inpatient group therapies should be chosen thoughtfully and monitored carefully.
Inpatient suicides are viewed as the most avoidable and preventable because they occur in close proximity to staff. The potential for suicide may be present from the initiation of hospitalization, but the ability to determine individuals at risk is difficult. Factors linked with suicide in the general population appear to differ from those associated with inpatient suicide. However, measures can be taken to try to reduce risk in the inpatient setting and during the time immediately after discharge. Reasonable steps should be taken to ensure the environment of care is designed to enhance patient safety including the removal of weight-supporting fixtures and rods, shoelaces and belts, razors, electrical appliances, plastic trash can liners, and unsecured windows.
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