New Sentinel Event Alert on preventing suicide in healthcare settings


The Joint Commission has issued a Sentinel Event Alert on preventing suicide in healthcare settings.

The new alert aims to assist healthcare providers, including primary, emergency and behavioral health clinicians, in better identifying and treating individuals with suicide ideation. The alert also provides screening, risk assessment, safety, treatment, discharge and follow-up care recommendations for at-risk individuals.

The Joint Commission is bringing attention to this issue because its Sentinel Event Database received 1,089 reports of suicides occurring from 2010 to 2014. The most common root causes documented were shortcomings in assessment, most commonly psychiatric assessment.

In addition, 21.4 percent of Joint Commission-accredited behavioral healthcare organizations and 5.14 percent of Joint Commission-accredited hospitals, for which a related National Patient Safety Goal was applicable, were non-compliant in 2014 with conducting a risk assessment that identifies specific patient characteristics and environmental features related to suicide risk.

“We are shining a light on this issue because the tragic reality is that many healthcare providers do not detect suicidal thoughts of individuals who eventually die by suicide, even though most victims of suicide received healthcare services in the year prior to death,” said Dr Ana Pujols McKee, executive vice president and chief medical officer, The Joint Commission.

“As a result, it is crucial for at-risk patients to receive timely and supportive care. Healthcare organizations are encouraged to develop clinical environment readiness by identifying, developing and integrating comprehensive behavioral health, primary and community care resources to assure the continuity of care for at-risk individuals.”

Healthcare providers across all settings play an important role in detecting suicide ideation, according to the alert. First, they should review each patient’s personal and family medical history for suicide risk factors, screen all patients for suicide ideation and review screening questionnaires before patients leave or are discharged.

Next, they should take immediate action for patients in acute suicidal crisis, as well as conduct safety planning for all patients with suicide ideation. Finally, they should manage evidence-based treatments and discharge plans that directly target suicidality, as well as participate in education on how to identify and respond to at-risk patients and document decisions regarding care and referral.

The Joint Commission, Sentinel Event Alert, Suicide, Healthcare, Dr Ana Pujols McKee, US, Crisis management