Citation

Dlugacz YD, Restifo A, Scanlon KA, Nelson K, Fried AM, Hirsch B, Delman M, Zenn RD, Selzer J, Greenwood A. Jt. Comm. J. Qual. Saf. 2003; 29(6): 267-278.

Copyright

(Copyright © 2003, Joint Commission on Accreditation of Healthcare Organizations)

DOI

10.1016/s1549-3741(03)29031-6

PMID

14564745

Abstract

BACKGROUND: Patient suicide is one of the primary sentinel events reported throughout the United States. North Shore-Long Island Jewish Health System undertook a series of performance improvement efforts to identify suicide risk factors and develop a series of strategies and tools to maximize the safety of all vulnerable patients.
METHODOLOGY: A multidisciplinary task force conducted root cause analyses of 17 attempted and completed suicides and targeted inadequate patient assessment, poor communication, and knowledge deficits. A protocol was designed to ensure appropriate assessment, monitoring, and treatment of patients at risk for alcohol withdrawal and suicide. Poor communication as patients moved throughout the continuum of care was addressed through targeted education, a centralized intake model, and an inter-institutional transfer summary form. A continuous suicide risk assessment tool was incorporated into the inpatient behavioral health rounds.
SUMMARY AND CONCLUSIONS: The new tools have raised awareness, improved accountability, and encouraged best practices throughout the health system.

Language: en

Keywords

Alcoholism; Clinical Protocols; Diagnosis, Dual (Psychiatry); Hospitals, Psychiatric; Humans; Male; Medical Records; Middle Aged; Multi-Institutional Systems; New York; Process Assessment, Health Care; Psychiatric Department, Hospital; Risk Assessment; Risk Management; Safety Management; Sentinel Surveillance; Software Design; Suicide; Suicide Prevention; Systems Analysis