Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 4 (Dec. 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Emergency Department Management of the Suicidal Patient • P A-PSRS has received several reports of patient suicide attempts, failed searches of suicidal pa- tients’ possessions, and elopements of suicidal pa- Placing the patient’s clothing and posses- sions in a secure location outside the room and not giving these items to family or tients from emergency departments (ED). Although friends.2 suicides, suicide attempts, and patient self-harm should be reported as Infrastructure Failures, facilities Often, aspects of the search are witnessed by or have reported them and their near-miss counterparts delegated to other staff. For example, security per- to the Patient Safety Authority (PSA). Suicidal pa- sonnel may be assigned to examine the patient’s pos- tients are evaluated and often held for observation in sessions (e.g., wallet, purse). The individual perform- the ED. Keeping an at-risk patient safe is a challenge ing the search looks for items that could cause harm. for an ED, as the following cases indicate: Any potentially harmful items, including medications, are documented and secured away from the patient.2 Patient took 100 Klonopin while on suicide watch in the ED. Providing a safe physical environment for suicidal patients often necessitates modification of the facil- Intoxicated, suicidal patient was brought to ity’s structural features, as well as furnishings and the ED by the police for observation over- equipment, in patient areas. Suggestions for review of night. Six hours later, the patient was not the environment, specifically the exam room, include there, and the bed was made. Security had the following: checked the room and thought the patient was discharged. • Assessing the area for items that might in- crease the risk of suicide by hanging, such as Patient came to the ED with suicidal ide- door hinges, plumbing fixtures, privacy parti- ations. The patient’s purse was not re- tions, clothing hooks, and closet and curtain moved from the room. The patient was rods. admitted to the ICU. Family members found the purse with medications in it. • Eliminating, to the extent possible, all means The purse was removed from the care of hanging such as sheets, pants, belts, area. shoelaces, any cords (e.g., the call-bell, elec- tronic equipment, and curtains or blinds). Heightened vigilance is warranted during the holiday Even something as seemingly benign as a season, when depression can be exacerbated and stethoscope, if left behind by a clinician, can substance abuse may be more likely. To optimize the become a strangulation device. safety of suicidal patients, consider the strategies be- • Using plastic utensils and disposable dishes low when reviewing policies and procedures for pa- for meals. tients at risk of suicide.1 • Minimizing access to glass by using Plexiglas Emergent care begins with expeditious triage of the for windows and any framed artwork.3 suicidal or at-risk patient, followed by a patient search. Search practices to consider include: This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. 4—Dec. 2005. The Advisory is a publication of the Pennsylvania Patient • Disrobing the patient and providing a hospi- Safety Authority, produced by ECRI & ISMP under contract to the Authority as tal gown. part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). • Searching the patient’s possessions for Copyright 2005 by the Patient Safety Authority. This publication may be re- weapons, medications, and any other items printed and distributed without restriction, provided it is printed or distributed in that can be used for self-harm. its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. To see other articles or issues of the Advisory, visit our web site at www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2 No. 4 (Dec. 2005) Emergency Departmental Management of the Suicidal Patient (Continued) • Eliminating materials that present a smother- Frequently, after a suicide attempt, patients are evalu- ing hazard, such as plastic shower curtains, ated and then transferred to other settings in the trash liners, and disposable gloves.4 chain of care. Structured collaboration is necessary between facilities during institutional transfers and Rooms that are designated for behavioral health pa- between teams during intrahospital transfers (e.g., tients but may be used for any patient when demand from the ED to the medical/surgical or psychiatric is high—brings with it risk. Housekeeping, contracted unit).5 services, and clinical staff may unwittingly leave items in the room that can enable determined patients to In an effort to provide the at-risk suicidal patient the inflict self-harm.3 Before placing an at-risk patient in safest care possible, be systematic about the patient an exam room, scan the room to ensure safety. search process, the environment of care, and the risk of elopement. Elopement is another risk among suicidal patients. Agitated, frightened, and often angry, suicidal patients Notes are likely to run away if the chance arises. Considera- 1. Drew BL. Self-harm behavior and no suicide contracting in psy- chiatric inpatient settings. Arch Psychiatr Nurs 2001 Jun;15(3):99- tions to minimize escape opportunities include: 106. 2. Initial management of potential suicidal/homicidal or potentially • Assigning the patient to a room in a location violent patients. ED Manag 2003 Jul;15(7 Suppl):1-3. that allows easy observation and access for 3. Yeager K, Saveanu R, Roberts A, et al. Measured response to staff yet is away from exits. identified suicide risk and violence: what you need to know about psychiatric patient safety. Brief Treat Crisis Interv 2005 May;5 • Monitoring and observation of the patient by (2):121-41. staff educated in observation of at-risk pa- 4. Nestor C. Suicide watch. Design your facility to protect troubled tients. patients from self-harm. Health Facil Manage 2000 Oct;13(10):24- 6. • Using a team-participation approach, with 5. Mann JJ, Apter A, Bertoltoe J, et al. Suicide prevention strate- scheduled, documented monitoring of the gies: a systematic review. JAMA 2005 Oct 26;294(16):2064-74. patient or, through intensive, one-to-one staff- ing when indicated. • Keeping the patient’s attire limited to a patient gown. Page 2 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 4 (Dec. 2005) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. ©2005 Pennsylvania Patient Safety Authority Page 3