Q&A: National Patient Safety Goal 15.01.01

Q: National Patient Safety Goal 15.01.01 says that the suicide of a patient while in a staffed, round-the-clock care setting is a frequently reported sentinel event, and that identifying at-risk individuals is an important step in protecting them. What does this mean for a nonbehavioral health environment? What should staff be doing to try to meet this goal?

A: In contrast to inpatient locked psychiatric units or psychiatric hospitals, medical-surgical units and most emergency departments (EDs) do not routinely assess every patient who comes in the door for suicide risk, and they are not environmentally designed or equipped to care for suicidal patients. The Joint Commission recommends that the following interventions be used for all patients presenting for treatment in an acute care nonbehavioral health setting, regardless of diagnosis or what problem they present with:

• Conduct suicide screening on all patients presenting to the ED.
• Screen all inpatients for depression.
• Educate staff on what medications are associated with increased suicide risk, either as a side effect of the medication itself or as an exacerbation of an underlying illness, such as epilepsy or bipolar disorder. Examples include some smoking-cessation drugs, mefloquine, interferons, amantadine, isotretinoin, and SSRIs.
• Routinely order psychiatric consults for patients admitted for medical treatment following a suicide attempt.
• Screen the hospital environment for suicide risk.

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