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2011 HSR&D National Meeting Abstract

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2011 National Meeting

3106 — Checklist to Identify Inpatient Suicide Hazards: Results from the First Two Years

Watts BV (WRJ VAMC), Mills PD (WRJ VAMC)

While considerable attention has been focused on the reduction of outpatient suicides among Veterans, less attention has been focused the prevention of suicide among Veterans hospitalized on inpatient psychiatric wards. Literature suggests that suicides occur while patients are hospitalized on mental health units at a surprisingly high rate both in the VA and the private sector. Use of standardized checklists has been found to be effective in improving safety of other clinical areas including surgical safety. We sought to determine the effectiveness of our checklist at decreasing inpatient suicide in the VA nationally.

After piloting testing the checklist at 10 sites, the VA mandated adherence to the checklist at all inpatient mental health units. We reviewed the VA National Center for Patient Safety database of all root cause analysis (RCA) done at all VA facilities from January 1999 to August 2010. Specifically we searched for completed suicides occurring on VA mental health inpatient units. We examined the RCAs from suicides completed after the deployment of the checklist to see if events occurred because of hazards unanticipated by the checklist or hazards founds by the application of the checklist, but not abated.

Prior to implementation of the checklist to identify suicide hazards on inpatient mental health wards the VA averaged 2.70 completed suicides per year (1999-2008). Since the implementation of the checklist the VA has averaged 1.24 suicides per year (2008-present). The longest period without a suicide also occurred after implementation of the checklist. We examined the suicides which occurred since implementation of the checklist. In each case the hazard was found using the checklist and was not abated either because of confusion about the requirement or delay in construction.

The use of the checklist to find and abate suicide hazards on inpatient mental health wards appears to be showing early effectiveness at decreasing the number of suicides on inpatient mental health units in the VA. Improving usability and clarity of the checklist may result in a further reduction.

Use of a checklist to identify hazards may decrease the rate of inpatient suicides in VHA.

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