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2015 HSR&D/QUERI National Conference Abstract

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3042 — Suicide on inpatient mental health units

Mills PD, VA National Center for Patient Safety;

Objectives:
Suicide was the tenth leading cause of death for all ages in 2010. There were 38,364 suicides in 2010 in the United States. In addition, an estimated 8.3 million adults reported having suicidal thoughts, 2.2 million reported having made suicide plans and 1 million reported making a suicide attempt in the past year; and 487,700 people were treated in emergency departments for self-inflicted injuries in 2011 1,500 suicides take place on inpatient psychiatry units in the US each year; over 70% by hanging. Understanding the methods and the environmental components of inpatient suicide may help to reduce its incidence.

Methods:
All Root Cause analysis (RCA) reports of suicide or suicide attempts in inpatient mental health units in VA hospitals between 12/1999 and 12/2013 were reviewed. We coded the method of suicide, anchor point and lanyard for cases of hanging, and implement for cutting; and brought together all other reports of inpatient hazards from VA staff for review.

Results:
There were 287 RCA reports of suicide attempts (257) and completions (30) on inpatient mental health unit: 42.8% were hanging, 21.5% were cutting, 17.8% were strangulation and 6.6% were overdoses. Doors accounted for 44.7% of the anchor points used hanging; sheets or bedding accounted for 59.4% of the lanyards. In addition, 19.5% of patients used razor blades for cutting. Use of a checklist to identify and remove suicide hazards is associated with a decrease in the rate of suicide from 2.64 per 100,000 admissions to 0.87 per 100,000 admission (p < .001).

Implications:
The most common method of suicide attempts and completions on inpatient mental health units is hanging. It is recommended that common lanyards and anchor points be removed from the environment of care. We provide more information about such hazards and introduce a decision tree to help healthcare providers to determine which hazards to remove.

Impacts:
Reviewing RCA reports of inpatient suicide, and using this information to develop a checklist to identify and remove suicide hazards lead to a reduction in completed suicides on inpatient mental health units in VHA.