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Publication Briefs

Improving the Environment of Care to Reduce Inpatient Suicide and Suicide Attempts in VA Facilities

Dr. Mills and Mr. DeRosier are with VA’s National Center for Patient Safety (White River Junction, VT and Ann Arbor, MI). Dr. Bagian is VA’s Chief Patient Safety Officer. Dr. Shepherd is with VA’s Office of Inspector General.

Suicide is the eleventh leading cause of death in the United States and approximately 1,500 suicides take place in inpatient hospital units each year. A recent study indicates that veterans are twice as likely as non-veterans to die of suicide. Previous suicide attempts are a primary risk factor for completed suicides, underscoring the importance of understanding and preventing not only completed but attempted suicides. In an effort to better understand the methods and environmental factors related to inpatient suicide and suicide attempts in VA hospitals, investigators in this study reviewed all Root Cause Analysis (RCA) reports relating to suicide or suicide attempts that were submitted to VA’s National Center for Patient Safety (NCPS) between 1999 and 2006. VA medical centers are required to report all completed suicides, serious suicide attempts, and related RCA’s to the NCPS.


  • A total of 185 RCA’s related to suicide were reported; 42 completed suicides and 143 suicide attempts.
  • While the majority of inpatient suicides and attempts occurred on psychiatry units (52%), 48% occurred in other areas of the hospital, most notably the emergency department.
  • Patient-induced drug overdose (18.9%), cutting with a sharp object (20.1%), and hanging (31.4%) accounted for 71.4% of the total number of events.
  • Of the 42 completed suicides, 18 (43%) were hangings, 15 (36%) were drug overdoses, and 4 (9.5%) were jumping from a high place. Of the 143 suicide attempts, 109 (76%) also involved the environment of care (e.g., jumping, cutting, hanging).
  • Authors make the following recommendations for reducing environmental hazards for suicide on inpatient psychiatric units: 1) Eliminate doors when not required by Code; 2) Remove doors on wardrobe cabinets, replace rods/hangers with shelves; 3) Eliminate belts, shoelaces, safety razors; shave high-risk patients or observe while shaving; 4) Ensure that there is a protocol to eliminate access to drugs that could be used for an overdose; and 5) Conduct environmental rounds using active observation skills and the “Environment of Care Checklist” implemented for use in VA inpatient psychiatric units as of September 2007.


  • Investigators did not control for patient characteristics (e.g., diagnosis, presence of psychosis, or severity of suicide risk) or facility characteristics (e.g., level of staffing, design of patient units).
  • The RCA database contained only reported events; it is possible some adverse events or close calls were not reported.

PubMed Logo Mills P, DeRosier J, Ballot B, Shepherd M, Bagian J. Inpatient Suicide and Suicide Attempts in Veterans Affairs Hospitals. Joint Commission Journal on Quality and Patient Safety August 2008;34(8):482-88.

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