3079 — Inpatient Suicide and Suicide Attempts in Veterans Affairs Hospitals

Mills PD (VA National Center for Patient Safety), Ballot B (VAMC West Palm Beach), Shepherd M (VA Office of the Inspector General), Bagian J (VA National Center for Patient Safety), DeRosier J (VA National Center for Patient Safety)

Objectives:
Suicide is the eleventh leading cause of death in the United States. Approximately 1500 suicides occur in inpatient hospital units in the United States each year. In order to understand the methods and environmental factors involved in inpatient suicide and suicide attempts in Veterans Affairs hospitals we reviewed all Root Cause Analysis (RCA) reports of inpatient suicides and suicide attempts submitted to the VA National Center for Patient Safety (NCPS) before June 2006.

Methods:
VA medical centers are required to conduct RCAs on all inpatient suicides and report all suicides and serious suicide attempts to the NCPS. We reviewed all reports of inpatient suicide and suicide attempts submitted between December 1999 and June 2006. We noted methods and environmental factors involved in the events.

Results:
Of the 185 reported events; 42 were completed suicides. More than half of the 185 events occurred while the patient was on an inpatient psychiatry unit. Primary methods were hanging(31.4%) cutting(20.1%) overdose(18.9%) strangulation(8%) and jumping(8%). Death resulted in 39% of overdoses, 31% of hangings, 14% of jumping, 3% of strangulation and 0% of cutting. Psychiatry units had most of the hanging(81%) and strangulation(64%) but only 44% of cuttings, 29% of overdoses, and none of the jumping. Doors and wardrobe cabinets accounted for 41.4% of the hanging anchor points; and bedding accounted for 39.7% of the noose material. Razor blades were used in 36.8% cutting cases, and balconies and walkways were used for 57.1% of the cases of jumping.

Implications:
Based on our preliminary findings, we recommend the following inpatient unit modifications to prevent suicide: 1. Eliminate doors when not required by Code. 2. Remove doors on wardrobe cabinets and replace rods and hangers with shelves. 3. Eliminate belts, shoelaces, and safety razors. 4. Eliminate access to drugs that could be used for an overdose. 5. Conduct environmental rounds using active observations skills and a comprehensive, checklist of potential environmental hazards.

Impacts:
Careful review of Root Cause Analysis reports of inpatient suicide has resulted in focused interventions to improve patient care and patient safety in VA including a comprehensive Environment-of-Care checklist for reviewing inpatient psychiatry units.