Retrospective analysis of reported suicide deaths and attempts on veterans health administration campuses and inpatient units

Abstract

IntroductionSuicide is the 10th leading cause of death in the USA. Inpatient suicide is the fourth most common sentinel event reported to the Joint Commission. This study reviewed root cause analysis (RCA) reports of suicide events by hospital unit to provide suicide prevention recommendations for each area.MethodsThis is a retrospective analysis of reported suicide deaths and attempts in the US Veterans Health Administration (VHA) hospitals. We searched the VHA National Center for Patient Safety RCA database for suicide deaths and attempts on inpatient units, outpatient clinics and hospital grounds, between December 1999 and December 2018.ResultsWe found 847 RCA reports of suicide attempts (n=758) and deaths (n=89) in VHA hospitals, hanging accounted for 71% of deaths on mental health units and 50% of deaths on medical units. Overdose accounted for 55% of deaths and 68% of attempts in residential units and the only method resulting in death in emergency departments. In VHA community living centres, hanging, overdose and asphyxiation accounted for 64% of deaths. Gunshot accounted for 59% of deaths on hospital grounds and 100% of deaths in clinic areas. All inpatient locations cited issues in assessment and treatment of suicidal patients and environmental risk evaluation.ConclusionsInpatient mental health and medical units should remove anchor points for hanging where possible. On residential units and emergency departments, assessing suicide risk, conducting thorough contraband searches and maintaining observation of suicidal patients is critical. In community living centres, suicidal patients should be under supervision in an environment free of anchor points, medications and means of asphyxiation. Suicide prevention on hospital grounds and outpatient clinics can be achieved through the control of firearms.

Multi-channel Small Animal Drug Metabolism Real-time Monitoring Fluorescence System

“…It can be seen from the above tests that the multi-channel real-time in vivo monitoring system for drug metabolism of small animals based on fluorescence proposed in this paper can achieve long-term continuous in vivo monitoring to meet the needs of in vivo monitoring of small animals. This method can replace some existing methods for acquiring blood concentration data, such as traditional methods for obtaining blood samples, high-performance liquid chromatography [26,27] and retrospective analysis methods [28,29]. three mice were killed at each time point to draw blood and collect organs for calculation.…”

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration

“…Our investigation of VHA hemodialysis-related bleeding events reinforced the well-recognized notion that multiple root causes underlie a patient harm event. 11 The action plans, however, ranged from weak to strong recommendations as identified by the VHA NCPS Action Hierarchy for Root Cause Analysis. 26 Updating existing policy and procedures or creating new or revised training is considered a weaker mitigation strategy.…”

“…Veterans Health Administration policy and prior NCPS publications have documented the process for reporting and investigating VHA patient safety events designed to be nonpunitive, identify root causes, and correct systems issues through action plans to mitigate future risk. 10,11 From January 2000 to June 2018, NCPS collected patient safety reports and RCA data in the SPOT database. In June 2018, collection of VHA patient safety reports was transitioned to the NCPS Joint Patient Safety Reporting (JPSR) system as a collaboration with the Department of Defense.…”

“…Two codebooks were developed to analyze JPSR and SPOT reports in accordance with previous NCPS publications. 11 The first codebook captured events by the type of vascular access present, patient mental status, whether the access site was visible or covered, and whether the bleeding event was identified by the staff during the dialysis treatment. The second codebook characterized RCA report root causes and action plans in a consensus manner by 3 of the authors (E.W., M.C., W.M..)…”

Mental health services: quality, safety and suicide

“…As recommended by the authors of a recent paper based on VHA postsuicide incident reports, different hospital and community settings need specific suicide prevention measures. 8 System-wide changes in mental health services can also improve safety. In a national before-and-after study conducted using NCISH data, we found that changes to mental health service provision designed to improve safety were indeed associated with lower suicide rates.…”