Article

Actions and Implementation Strategies to Reduce Suicidal Events in the VHA

Field Office, VA National Center for Patient Safety, White River Junction, Vermont, USA.
Joint Commission journal on quality and patient safety / Joint Commission Resources 04/2006; 32(3):130-41.
Source: PubMed

ABSTRACT

Veterans possess many risk factors for suicide, making suicide prevention in the Veterans Health Administration (VHA) a particular challenge.
An analysis was conducted of 94 aggregated root cause analyses (RCAs) for parasuicidal behavior and 43 single-case suicide RCAs submitted from 75 VHA facilities to determine primary root causes for suicide and parasuicidal behaviors and to gain information about action plans, success factors and obstacles to improvement. Telephone follow-up interviews were conducted with each facility.
The aggregate reviews included 775 individual cases of parasuicidal behavior. The top root causes of parasuicidal behavior were poor assessment and communication of patient risk, patient stressors, and need for staff and patients training. Forty-eight percent of the action plans developed to address the root causes involved a policy change, 30% involved staff training, and 14% involved making a specific clinical change. Eight-eight percent of the actions adequately addressed the root cause, of which 68.1% were fully implemented.
There is little agreement on the definition of "parasuicide," and it is likely the case that parasuicide behaviors are underreported in our system. To encourage reporting, patient safety staff should collaborate with providers and use a more inclusive definition of parasuicide.

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    • "Because the RCA process may be open to bias (Clarke, 2008; Nicolini et al., 2011) and oversimplify multiple complex factors (Clarke, 2008), the development of tools and processes that can enhance reproducibility , optimize analysis, and validate the framework in health care is recommended (Percarpio, Watts, & Weeks, 2008; Nicolini et al., 2011; Taitz et al., 2010). Given the additional complexities of suicide compared with adverse events in other health-care settings, there is a particular need for mental health services to identify processes that can be used to standardize the review of suicides (Clarke, 2008; Mills et al., 2006) in order to systematically review across RCA findings and identify service-wide prevention strategies (Clarke, 2008; Nicolini et al., 2011). "
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    ABSTRACT: Background: The ability to predict imminent risk of suicide is limited, particularly among mental health clients. Root cause analysis (RCA) can be used by health services to identify service-wide approaches to suicide prevention. Aims: To (a) develop a standardized taxonomy for RCAs; (b) to quantitate service-related factors associated with suicides; and (c) to identify service-related suicide prevention strategies. Method: The RCAs of all people who died by suicide within 1 week of contact with the mental health service over 5 years were thematically analyzed using a data collection tool. Results: Data were derived from RCAs of all 64 people who died by suicide between 2008 and 2012. Major themes were categorized as individual, situational, and care-related factors. The most common factor was that clients had recently denied suicidality. Reliance on carers, recent changes in medication, communication problems, and problems in follow-through were also commonly identified. Conclusion: Given the difficulty in predicting suicide in people whose expressions of suicidal ideation change so rapidly, services may consider the use of strategies aimed at improving the individual, stressor, support, and care factors identified in this study.
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