Patient Safety: Lessons Learned

Ensuring the safety of vulnerable patients

By Alexis Reeves, RN, Director of Patient Safety Operations & Implementation

There has been increased media attention to suicides in the United States, especially in relation to the rising incidence of suicides among returning veterans. As we know all too recently, Stanford is not immune to the incidence of inpatient suicides. When a vulnerable individual seeks attention from a medical facility, there is a common belief among staff that the person is safe having sought out medical care. But this is a dangerous misconception. According to the Joint Commission, there were 1,089 inpatient suicides reported from accredited hospitals from 2010 to 2014. The numbers are so alarming that the Joint Commission issued a Sentinel Events Alert on the importance of identifying vulnerable patients in the hospital setting. 

The Joint Commission noted that the “greatest clinical root cause of inpatient suicides is a failure in clinical assessment.” Hospitals also often fail to institute appropriate precautions based on an admitted patient’s assessed risk level. The greatest risk occurs when the patient is left alone.

As the inpatient population at Stanford continues to be more diversified, our vulnerability increases. Physician and staff vigilance must be heightened in order to prevent inpatient suicides. At the same time, our internal systems must include all the necessary precautions to ensure the safety of our patients, and at the same time, provide clinicians the tools they need for appropriate risk assessments. There is ongoing work within the organization to address this vulnerability and ensure compliance of Joint Commission standards. A workgroup is currently analyzing and updating SHC’s primary policies and procedures for caring for vulnerable patients. There are additional patient protocols for the psychiatric unit and the emergency department.

Listed here are some of the Joint Commission’s general recommendations for decreasing the risk of inpatient suicide:

• More stringent assessment and monitoring of a patient’s risk
• Better monitoring of behavioral signs and symptoms
• Improve staff communication of signs and risk
• Wait for significant, stable, reliable change before relaxing precautions
• Improve sub-optimal staff-patient relationships
• Gather collateral information
• Do not rely solely on patient self-report of no suicidal ideation
• Do not rely on “no suicide” contracts
• Ensure a safe physical environment that is devoid of a means to commit suicide or access to hidden areas. Units should be periodically checked to ensure suicide-proof architecture
• Avoid over-confidence in or over-reliance on 15-minute checks
• Avoid premature discharge
• Provide a smooth, tight transition to outpatient care
• Base suicide precautions on an adequate risk assessment and clinical rationale
• Document risk assessment and clinical rationale
• Form a suicide prevention committee

If you have any questions about SHC’s protocols for managing vulnerable patients, please contact Alexis Reeves, alreeves@stanfordhealthcare.org, 650-724-7548.