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Physical features can help prevent suicide, patient self-harm


September 28, 2017

Consider using roll-down doors on emergency department exam rooms, breakaway clothes hooks on walls, and cone-shaped or push-pull handles for doors to decrease the physical risk of patient harm while also protecting your facility from costly Requirements for Improvement (RFI). 

Year after year, suicides continue to be among the top most reviewed sentinel events by The Joint Commission, moving from fourth place in 2013 to third in 2014 and staying there for 2015, according to information released by the accreditor in February. 

In 2015, 95 suicide events were reviewed, up from 82 in 2014 and 90 events the year before that. In addition, the number of self-inflicted injury events reviewed by The Joint Commission has also spiked, going from five in 2014 to 21 in 2015. 

The reporting of sentinel events is voluntary, and The Joint Commission itself notes that those numbers reflect only a small number of actual events. 

But you can be sure that any time the accreditor finds out about a suicide, whether self-reported, through news reports, or other means, commission surveyors will be on-site shortly thereafter, notes Ernest Allen, ARM, CSP, CPHRM, CHFM, a former surveyor and now patient safety account executive with The Doctor’s Company, based in Napa, California.

“Within a month they’re going to be knocking on the door,” Allen warned hospital facility managers, engineers, safety specialists, and others at last fall’s EC Summit. 

CMS surveyors might follow, as could state health department officials and the lawyers of surviving family members, Allen said.

Surveyors have many ways to cite problems 

Suicides can be cited under several requirements, including: 

  • National Patient Safety Goal 15: Hospitals are required to identify safety risks inherent in the patient population. For patients at risk of suicide, NPSG.15.01.01, EP 1, specifically calls for a documented risk assessment that includes environmental features “that may increase or decrease the risk for suicide.” 
  • Environment of Care standard EC.02.01.01: The hospital must manage safety and security risks, including under EP 1 those associated with the environment of care and identified through internal sources such as “ongoing monitoring of the environment,” root cause analysis, and proactive risk assessments and external causes such as Sentinel Event Alerts. EP 3 requires the hospital to take action to minimize or eliminate identified physical risks.
  • EC.02.06.01: The hospital must have and maintain a “safe, functional environment,” which includes under EP 1 the requirement that interior spaces meet the needs of the patients and are “safe and suitable to the care, treat¬ment, and services provided.” Hospitals must also show a measure of success under EP 1. 

Those deficiencies might be found by the life safety surveyor but are just as likely, and perhaps these days more so, to be cited by the nurse or even physician surveyor, Allen warned. “It’s a growing issue.” 

While patients can get very creative when looking for ways to harm themselves, hanging is a frequent choice, often using a bedsheet, said Allen. A review of insurance claims shows such methods as hanging from a towel rack, the side of a bedrail, or a curtain rod; patients have also used a belt in a closet, tied a treadmill cord to the ceiling of an exercise room, or hooked a bedsheet over the top of a bathroom door. 

Physical modifications to rooms and equipment can decrease the risk of self-harm. 

For more information on ways to safeguard your phys¬ical environment, the National Association of Psychiatric Health Systems' “Design Guide for the Built Environment of Behavioral Health Facilities” is now available as a free download at the Facility Guidelines Institute.  

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