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Inpatient Suicide and Suicide Attempts in Veterans Affairs Hospitals

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Background: Suicide is the eleventh leading cause of death in the United States. Approximately 1,500 suicides occur in inpatient hospital units in the United States each year. In an attempt to determine the methods and environmental factors involved in inpatient suicide and suicide attempts in Department of Veterans Affairs (VA) hospitals, all root cause analysis (RCA) reports of inpatient suicides and suicide attempts submitted to the VA National Center for Patient Safety (NCPS) before June 2006 were reviewed.

Methods: VA medical centers are required to conduct RCAs on all inpatient suicides and report all suicides and serious suicide attempts to the NCPS. All reports of inpatient suicide and suicide attempts submitted between December 1999 and June 2006 were reviewed, including methods and environmental factors involved in the events.

Results: A total of 185 inpatient suicide and suicide attempts were reported; 42 were completed suicides and 143 were suicide attempts. Approximately 52% of the total number of events occurred while the patient was on an inpatient psychiatry unit. Three methods of self harm—intentional drug overdose, cutting with a sharp object, and hanging—accounted for 71% of the total number of events. Doors and wardrobe cabinets accounted for 41% of the anchor points when hanging was the method of self-harm. For suicide attempts involving cutting behaviors, razor blades accounted for 37% of the total number of events; 57% of jumping-related events occurred from balconies and walkways.

Conclusions: Careful review of RCA reports of inpatient suicide has resulted in focused interventions to improve patient care and patient safety in VA medical centers, including a comprehensive environment-of-care checklist for reviewing inpatient psychiatry units.

Document Type: Research Article

Publication date: August 1, 2008

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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.

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