Sentinel Events Update: Suicides in Hospitals : Accreditation Updates

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Sentinel Events Update: Suicides in Hospitals

by Joint Commission Resources Quality and Safety Network on 11/06/18

Joint Commission researchers recently published an article that provides the first data-driven estimate of the number of suicides in hospitals in the United States in The Joint Commission Journal on Quality and Patient Safety. The study analyzed suicide data from the US Centers for Disease Control and Prevention National Violent Death Reporting System (NVDRS) and from the Joint Commission’s Sentinel Event Database.

The study concluded that approximately 49 to 65 hospital inpatient suicides occur each year in the United States. Of these, 75% to 80% are expected to be psychiatric inpatients. Among psychiatric inpatients, the estimated inpatient suicide rate was 3.2 per 100,000 psychiatric inpatient admissions; among non-psychiatric inpatients, the rate was very low, at 0.03 per 100,000 admissions. The results from this study provide a more reliable benchmark of the national inpatient suicide rate for policymakers, regulators, accrediting organizations, health care providers, and researchers to use when making decisions regarding the allocation of resources and implementation of specific requirements to prevent inpatient suicides.

In the coming months, The Joint Commission will publish a fully revised National Patient Safety Goal (NPSG) 15.01.01, which requires hospitals and behavioral health care organizations to reduce the risk of suicide. NPSG.15.01.01 will include revised requirements related to the following topics:

  • Assessing and mitigating environmental risks
  • Suicide screening and assessment
  • Documentation of patients’ overall level of risk for suicide and the plan to mitigate the risk for suicide
  • Monitoring patients who are at high risk for suicide
  • Counseling and follow-up care at discharge

This revised NPSG is designed to not only help reduce the risk of inpatient suicide, but to help organizations identify, counsel, and coordinate care for an even larger group of patients who are at risk for suicide after they are discharged to the community.





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