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Safety Strategies to Prevent Suicide in Multiple Health Care Environments

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Background: Patient suicide is one of the primary sentinel events reported throughout the United States. North Shore–Long Island Jewish Health System undertook a series of performance improvement efforts to identify suicide risk factors and develop a series of strategies and tools to maximize the safety of all vulnerable patients.

Methodology: A multidisciplinary task force conducted root cause analyses of 17 attempted and completed suicides and targeted inadequate patient assessment, poor communication, and knowledge deficits. A protocol was designed to ensure appropriate assessment, monitoring, and treatment of patients at risk for alcohol withdrawal and suicide. Poor communication as patients moved throughout the continuum of care was addressed through targeted education, a centralized intake model, and an inter-institutional transfer summary form. A continuous suicide risk assessment tool was incorporated into the inpatient behavioral health rounds.

Summary and conclusions: The new tools have raised awareness, improved accountability, and encouraged best practices throughout the health system.

Document Type: Research Article

Publication date: June 1, 2003

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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