The goal of this study was to describe suicide and suicide attempts that occurred while the patient was on hospital grounds, common spaces, and clinic areas using root cause analysis (RCA) reports of these events in a national health care organization in the United States.
This is an observational review of all RCA reports of suicide and suicide attempts on hospital grounds, common spaces, and clinic areas in our system between December 1, 1999, and December 31, 2014. Each RCA report was coded for the location of the event, method of self-harm, if the event resulted in a death by suicide, and root causes.
We found 47 RCA reports of suicide and suicide attempts occurring on hospital grounds, common spaces, or clinic areas. The most common methods were gunshot, overdose, cutting, and jumping, and we have seen an increase in these events since 2011. The primary root causes were breakdowns in communication, the need for improved psychiatric and medical treatment of suicidal patients, and problems with the physical environment.
Hospital staff should evaluate the environment for suicide hazards, consider prohibiting firearms, assist patients with no appointments, and promote good communication about high-risk patients.
From the *VA National Center for Patient Safety, White River Junction, VT; and †The Geisel School of Medicine at Dartmouth College, Hanover, NH.
Correspondence: Peter D. Mills, PhD, MS, VA National Center for Patient Safety Field Office, VAMC, 215 N Main St, White River Junction, VT 05009 (e-mail: Peter.Mills@va.gov).
This material is the result of work supported with resources and the use of facilities at the Department of Veterans Affairs National Center for Patient Safety at Ann Arbor, Michigan, and the Veterans Affairs Medical Centers, White River Junction, Vermont. The Research and Development Committee, White River Junction, VA Medical Center approved this project, and the Committee for the Protection of Human Subjects, Dartmouth College considered this project exempt. The views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or of the United States government. We are submitting this as original research; we have not reported these data in any other forum, and none of the authors has any conflict of interest regarding this report. This work was supported by the Department of Veterans Affairs, and as a government product, we do not hold the copyright.
The authors disclose no conflict of interest.