Medical/Dental Professionals

Quality and Safety

Learn to Recognize Suicide Risk Factors

Did you know that suicide is the 10th leading cause of death in the United States? According to the Centers for Medicare and Medicaid (CMS) and DNV GL Healthcare, patients have a right to care in a safe setting and, in order to provide care in a safe setting, hospitals must identify patients at risk for intentional harm to self or others, identify environmental safety risks for such patients, and provide education and training for staff and volunteers. 

Hospitals must educate staff about the identification of patients at risk of harm to self or others, and the identification of environmental patient safety risk factors and mitigation strategies. 

Indicators that increase suicide risk include, but aren’t limited to: depression, acute/chronic mental health illness, prior suicidal gestures/attempts, overdose, substance abuse, alcohol withdrawal, family history of suicide, social isolation and lack of support system, terminal and/or chronic medical conditions. 

Physical illnesses associated with suicide include: multiple sclerosis, epilepsy, spinal cord injury, delirium tremors, Huntington’s disease, cancer, Cushing’s disease, renal failure/on dialysis, and chronic pulmonary disease.

How We Keep Our Suicidal Risk Patients in a Safe Environment

Keeping our suicidal risk patients in a safe environment is a requirement of the Centers for Medicare and Medicaid (CMS). A safe environment is one in which the area has been evaluated for potential items that could pose a risk of harm to a patient or staff person. Any items identified that pose a risk are removed or a plan is implemented to reduce the associated risk.

It’s vital to mitigate any risks within the suicidal risk patient’s environment to ensure that they are safe. At Kaleida Health, a unit-by-unit Environmental Risk Assessment was done and documented to include areas of the unit (including patient’s rooms) that had possible ligature risk, defined by CMS as: “Anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation.”

We utilize the Suicide and Patient Safety Checklist found on Forms on Demand to ensure the patient’s environment is as safe as possible and that any items that aren’t medically necessary are removed from the room. Some examples of ligature risk items includes: plastic bags, extra linen in room, strings/elastic on patient garment, IV tubing and items brought in by visitors.