Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports

J Nerv Ment Dis. 2017 Jun;205(6):436-442. doi: 10.1097/NMD.0000000000000687.


There is a high risk for death by suicide after discharge from an inpatient mental health unit. To better understand system and organizational factors associated with postdischarge suicide, we reviewed root cause analysis reports of suicide within 7 days of discharge from across all Veterans Health Administration inpatient mental health units between 2002 and 2015. There were 141 reports of suicide within 7 days of discharge, and a large proportion (43.3%, n = 61) followed an unplanned discharge. Root causes fell into three major themes including challenges for clinicians and patients after the established process of care, awareness and communication of suicide risk, and flaws in the established process of care. Flaws in the design and execution of processes of care as well as deficits in communication may contribute to postdischarge suicide. Inpatient teams should be aware of the potentially heightened risk for suicide among patients with unplanned discharges.

Publication types

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

MeSH terms

  • Adult
  • Aged
  • Cause of Death*
  • Female
  • Homeless Persons / statistics & numerical data*
  • Hospitals, Veterans / statistics & numerical data
  • Humans
  • Male
  • Middle Aged
  • Pain / epidemiology*
  • Patient Compliance / statistics & numerical data*
  • Patient Discharge / statistics & numerical data*
  • Psychiatric Department, Hospital / statistics & numerical data*
  • Retrospective Studies
  • Root Cause Analysis / methods*
  • Suicide / statistics & numerical data*
  • Time Factors
  • United States
  • United States Department of Veterans Affairs / statistics & numerical data
  • Young Adult