2005 HSR&D National Meeting Abstract

3064 — Results of Aggregate Root Cause Analysis of Suicide and Para-Suicidal Behaviors in the VA System

Author List:
Mills PD (VA National Center for Patient Safety)
Neily J (VA National Center for Patient Safety)
Luan D (VA National Center for Patient Safety)
Osborne A (VA National Center for Patient Safety)
Hirschler KH (VA National Center for Patient Safety)

Objectives:
To examine parasuicidal aggregate reviews within the VHA, providing a description of how suicide and parasuicidal behaviors are addressed. We reviewed all of the aggregated reviews submitted as well as a group of outstanding single case root cause analyses. We hope to give health care providers practical ideas for reducing suicide and parasuicidal behaviors as well as suggest methods for measuring the results of their interventions.

Methods:
We coded and analyzed 94 aggregated root cause analyses for parasuicidal behavior submitted from 59 VHA facilities. In addition, 43 single case suicide Root Cause Analyses from 34 VHA facilities were reviewed. Telephone follow-up interviews were conducted with each facility

Results:
A total of 775 cases of parasuicidal behavior were reviewed in the 94 aggregate reviews. The mean number of cases reviewed per aggregated RCA was 8.5. It took an average of 33.5 person hours to complete an aggregated RCA. The top contributing factors were: poor communication, rules and policy changes, patient stressors, and poor staff training. Forty-eight percent of the actions involved a policy change, 30% involved staff training and 14% involved making a specific clinical change. Eighty-eight percent of the actions adequately addressed the root cause; of those 68.1% were fully implemented. Facilities differed in their definition of parasuicidal events and the outcomes used to measure change. Primary success factors for making improvements included support from middle and senior management as well as the front-line staff, enough staff and resources to make the change, and a system for following-up.

Implications:
Reduction of suicidal and parasuicidal behavior is a challenge due to under-reporting, the variety of definitions of parasuicidal events and the lack of clear evidence of effective clinical interventions.

Impacts:
Better tools and approaches are needed to aid in suicide assessment Encourage reporting by making it easier and less time-consuming for providers. Use a well-organized tracking system for actions. Senior leadership needs to demonstrate that reducing suicidal behavior is a priority by devoting resources and staff to implement actions. Develop effective collaboration with mental health providers. Develop and implement methods for sites to share information with others who have successfully reduced suicides.