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Checklist Successfully Identifies VA Environmental Hazards for Inpatient Suicide


In 2003, the American Psychiatric Association reported that about 1,500 suicides take place in inpatient hospital units in the U.S. each year, while another review by The Joint Commission found that 75% involved hanging. A recent study of inpatient suicide in VA hospitals also found that hanging was the most common method (43%). In 2006, a multi-disciplinary VA committee was charged with developing a checklist to identify environmental hazards on acute mental health units treating suicidal Veterans. The committee developed both general guidelines to be applied to all areas of the psychiatric unit, as well as detailed guidelines for specific rooms (e.g., bathrooms, bedrooms). In 2007, the Mental Health Environment of Care Checklist* became mandatory in all VA mental health units treating suicidal Veterans. This is the first study to examine the implementation and effectiveness of using a standardized checklist for mental health units to improve patient safety.

Findings show that by the end of the first year of the project - October 2008, 7,642 environmental suicide hazards had been identified and 5,834 (76.3%) had been abated. Approximately 2% of these suicide hazards were identified as critical, and another 27% were rated as serious. The most common hazard was anchor points for hanging (44%); anchor points also presented the greatest risk level, followed by suffocation and poison. High-risk locations included bedrooms and bathrooms.

In addition (to be noted in Journal's blog - coming soon), the authors state that throughout 2009 and 2010, VA facilities continued to use the checklist to evaluate mental health units on a quarterly basis. More than 2000 new hazards were identified in the second year, suggesting that as more obvious hazards are identified and abated, VA staff began to recognize more subtle hazards.

*The Mental Health Environment of Care Checklist is available at www.patientsafety.gov/SafetyTopics.html .

PubMed Logo Mills P, Watts B, Miller S, et al. A checklist to identify inpatient suicide hazards in Veterans Affairs Hospitals. The Joint Commission Journal on Quality and Patient Safety February 2010;36(2):87-93.

This study was supported through the VA National Center for Patient Safety located in Ann Arbor, MI and White River Junction, VT. Drs. Mills, Watts, DeRosier, and Bagian are part of VA's National Center for Patient Safety.

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HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR&D based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.