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Publication Briefs

Study Examines Factors Associated with Suicide within One Week of Discharge from VA Psychiatric Facilities

Several studies have shown that patients are at increased risk for death by suicide in the year following discharge from an inpatient mental health unit. To better understand system and organizational factors associated with post-discharge suicide, this study reviewed root-cause analysis (RCA) reports of death by suicide within seven days of discharge from all VA inpatient mental health units (112 VA facilities) between FY2002 and FY2015. The National Center for Patient Safety (NCPS) oversees safety efforts within VA and maintains a RCA database; each RCA report includes one or more root causes. From the RCA reports, investigators abstracted a relevant set of available patient-level data to characterize the study population, including the following variables thought to be associated with suicide risk: gender, age, length of stay, homelessness, acute or chronic pain, and treatment non-adherence.


  • Risk for suicide for Veterans in the week following hospital discharge may be highest during the first few days after discharge. There were 141 reports of suicide within seven days of discharge: 40% occurred during the first day of discharge; 67% within 72 hours of discharge, and nearly 80% within four days of discharge. Further, 43% of suicides followed an unplanned discharge. In comparison, there were 7,400 Veteran deaths by suicide overall in 2014.
  • Root causes for suicide fell into three major categories: 1) challenges for clinicians and patients following the established process of care, 2) awareness and communication of suicide risk, and 3) flaws in the established process of care.
  • No association was found between length of hospital stay and days to suicide.
  • Many hospitalized Veterans were described as homeless (20%), having symptoms of pain (22%), or having a history of treatment non-compliance (22%).


  • Current VA policies mandating mental health follow-up within 7 days of discharge may be insufficient. Also, other methods of intervention to better reach this vulnerable patient population may need to be considered (e.g., tele-monitoring). The authors also suggest that inpatient teams be aware of the potentially heightened risk for suicide in patients whose discharge is unplanned.


  • Although RCA provides a standardized approach for evaluating system factors that contribute to adverse events, the lack of a comparison group limits the ability to draw robust conclusions.
  • Because the RCA databes cannot be linked directly to patient records, investigators were unable to account for important patient characteristics, such as mental health and/or substance abuse history.
  • While VA requires that an RCA be performed for death by suicide within 1 week of discharge from a mental health unit, authors were unable to determine whether there was under-reporting. Therefore, results should be used to understand organizational vulnerabilities and opportunities for improvement rather than as epidemiologic estimates.

This work was sponsored by the National Center for Patient Safety Center of Inquiry Program Dr. Shiner is supported by an HSR&D Career Development Award.

PubMed Logo Riblet N, Shiner B, Watts B, et al. Death by Suicide within One Week of Hospital Discharge: A Retrospective Study of Root-Cause Analysis Reports. Journal of Nervous and Mental Disease. June 2017;205(6):436-42.

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