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Actions and Implementation Strategies to Reduce Suicidal Events in the Veterans Health Administration

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Abstract:

Background: Veterans possess many risk factors for suicide, making suicide prevention in the Veterans Health Administration (VHA) a particular challenge.

Methods: An analysis was conducted of 94 aggregated root cause analyses (RCAs) for parasuicidal behavior and 43 single-case suicide RCAs submitted from 75 VHA facilities to determine primary root causes for suicide and parasuicidal behaviors and to gain information about action plans, success factors and obstacles to improvement. Telephone follow-up interviews were conducted with each facility.

Results: The aggregate reviews included 775 individual cases of parasuicidal behavior. The top root causes of parasuicidal behavior were poor assessment and communication of patient risk, patient stressors, and need for staff and patients training. Forty-eight percent of the action plans developed to address the root causes involved a policy change, 30% involved staff training, and 14% involved making a specific clinical change. Eight-eight percent of the actions adequately addressed the root cause, of which 68.1% were fully implemented.

Discussion: There is little agreement on the definition of "parasuicide," and it is likely the case that parasuicide behaviors are underreported in our system. To encourage reporting, patient safety staff should collaborate with providers and use a more inclusive definition of parasuicide.

Document Type: Research Article

Publication date: March 1, 2006

More about this publication?
  • 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.

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