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Death by Suicide Within 1 Week of Hospital Discharge

A Retrospective Study of Root Cause Analysis Reports

Riblet, Natalie MD, MPH*†‡; Shiner, Brian MD, MPH*†‡; Watts, Bradley V. MD‡§; Mills, Peter PhD‡§; Rusch, Brett MD*†; Hemphill, Robin R. MD, MPH§

The Journal of Nervous and Mental Disease: June 2017 - Volume 205 - Issue 6 - p 436–442
doi: 10.1097/NMD.0000000000000687
Original Articles

There is a high risk for death by suicide after discharge from an inpatient mental health unit. To better understand system and organizational factors associated with postdischarge suicide, we reviewed root cause analysis reports of suicide within 7 days of discharge from across all Veterans Health Administration inpatient mental health units between 2002 and 2015. There were 141 reports of suicide within 7 days of discharge, and a large proportion (43.3%, n = 61) followed an unplanned discharge. Root causes fell into three major themes including challenges for clinicians and patients after the established process of care, awareness and communication of suicide risk, and flaws in the established process of care. Flaws in the design and execution of processes of care as well as deficits in communication may contribute to postdischarge suicide. Inpatient teams should be aware of the potentially heightened risk for suicide among patients with unplanned discharges.

*Veterans Affairs Medical Center, White River Junction, Vermont; †The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon; ‡Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and §Veterans Affairs National Center for Patient Safety, Ann Arbor, Michigan.

Send reprint requests to Natalie Riblet, MD, MPH, Veterans Affairs National Center for Patient Safety Field Office, 215 North Main Street, White River Junction, VT 05009. E-mail:

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