Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards

Gen Hosp Psychiatry. 2013 Sep-Oct;35(5):528-36. doi: 10.1016/j.genhosppsych.2013.03.021. Epub 2013 May 20.


Introduction: One thousand five hundred suicides take place on inpatient psychiatry units in the United States each year, over 70% by hanging. Understanding the methods and the environmental components of inpatient suicide may help to reduce its incidence.

Methods: All Root Cause Analysis reports of suicide or suicide attempts in inpatient mental health units in Veterans Affairs (VA) hospitals between December 1999 and December 2011 were reviewed. We coded the method of suicide, anchor point and lanyard for cases of hanging, and implement for cutting, and brought together all other reports of inpatient hazards from VA staff for review.

Results: There were 243 reports of suicide attempts and completions: 43.6% (106) were hanging, 22.6% (55) were cutting, 15.6% (38) were strangulation, and 7.8% (19) were overdoses. Doors accounted for 52.2% of the anchor points used for the 22 deaths by hanging; sheets or bedding accounted for 58.5% of the lanyards. In addition, 23.1% of patients used razor blades for cutting.

Conclusions: The most common method of suicide attempts and completions on inpatient mental health units is hanging. It is recommended that common lanyards and anchor points be removed from the environment of care. We provide more information about such hazards and introduce a decision tree to help healthcare providers to determine which hazards to remove.

Keywords: Inpatient; Patient safety; Root Cause Analysis; Suicide.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Hospitals, Veterans / statistics & numerical data*
  • Humans
  • Inpatients / psychology
  • Patient Safety
  • Psychiatric Department, Hospital / statistics & numerical data*
  • Retrospective Studies
  • Root Cause Analysis
  • Suicide / statistics & numerical data
  • Suicide Prevention*