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Tuesday April 20, 2021  |  Stephanie Sales, MBA, MSN, RN, LP, Director, EDIS Product Management

Part I – 2021 Hospital National Patient Safety Goals Series: Identifying Patient Safety Risks

Part I – 2021 Hospital National Patient Safety Series- Identifying Patient Safety Risks EHR

Each year The Joint Commission gathers information about emerging patient safety concerns and sets standards and measurable outcomes to help hospitals improve performance and continue to provide high-quality care.

These standards are applicable to all Joint Commission-accredited hospital and behavioral health care organizations.

In this series, we will focus on ways to address the National Patient Safety Goal (NPSG) 15.01.01 which works to identify patient safety risks. This first blog overviews identifying and reducing the risk of patient suicide, which is the NPSG target for 2021.

Identifying and Preventing Patient Suicide Risks

According to a study from The Joint Commission Journal on Quality and Patient Safety, there are approximately 30,000 suicides per year in the United States. It is estimated that 5 to 6 percent of those suicides occur in hospitals. In addition, the overall suicide rate is markedly higher in rural areas as compared to urban areas.

To help hospitals effectively meet the NPSG standard for compliance, an R3 Report by The Joint Commission identifies seven elements of performance (EP) designed to decrease suicide rates in this high-risk group.

Element of Performance 1

For effective prevention of suicides in non-psychiatric units in a general hospital, procedures must be implemented to mitigate suicide risk, such as:

  • Removing objects that could cause harm
  • Providing one-on-one monitoring
  • Assessing objects that visitors bring into patient rooms

For psychiatric units, removing door hinges, hooks that can be used for hanging, and anchor points are important measures. The rationale is that most common patient areas contain hazards that pose a risk for suicidal patients. By removing the hazard, it minimizes suicide risk.

Element of Performance 2

The second requirement asks healthcare providers to screen all individuals being treated or evaluated for behavioral health conditions with a validated screening tool starting at age 12 and above. The R3 report also states patients being treated for behavioral health problems often have suicidal ideation.

Element of Performance 3

An evidence-based process is required for those patients who have screened positive for suicidal ideation. It is important to complete an in-depth assessment in order to determine how to appropriately treat these patients.

Element of Performance 4

This EP requires the documentation of the patient’s overall level of risk for suicide, as well as a plan to mitigate the risk.

Element of Performance 5

To address care for those at risk, written policies and procedures must be followed.

Staff should be properly trained to identify and assess those at high risk for suicide and follow guidelines for reassessment of the patient. These policies should be guided by an evidence-based practice.

Element of Performance 6

Given that the risk for suicide is very high after discharge from the emergency department or an inpatient psychiatric setting, written policies and procedures for counseling and follow-up care at discharge are critical.

Developing a safety plan with the patient can decrease suicidal behavior. One way to provide additional support is to provide the patient with numbers to crisis call centers.

Elements of Performance 7

Processes for monitoring the implementation and effectiveness of policies and procedures tied to the screening, management, and assessment of at-risk patients are required. Strict adherence to protocols is the only way to ensure there is a high reliability of suicide prevention.

Patient Suicide Risk and COVID-19

COVID-19, and the challenges that communities have faced related to isolation alongside COVID-19-associated morbidity and mortality, have led to an increased number of mental health, substance abuse, and suicidal ideation.

The Centers for Disease Control (CDC) reports that during June 24-30, 2020, 40 percent of adults surveyed reported an increase in mental health symptoms such as anxiety and depression. When compared to a similar 2019 survey in the same timeframe, a significant year-to-year rise in such responses is clear.

In addition, increased substance abuse and elevated suicidal ideation were also reported by younger adults, essential workers, unpaid adult caregivers, and racial/ethnic minorities.

Does Your EDIS Offer Resources for Effective Suicide Screening?

In many cases, high suicide-risk patients present at the emergency room before transitioning to the inpatient setting. The Emergency Nurses Association (ENA) stance as a leading and influential voice on the public policies affecting emergency nursing and suicide screening underscores this point.

On September 29, 2020, the House passed H.R. 4861, the Effective Suicide Screening and Assessment in the Emergency Department Act of 2020. This legislation establishes a competitive grant program to help train up to 40 hospitals with emergency departments to connect patients who are at risk for suicide with treatment and mental health services. This grant can also be used to train emergency department providers, establish policies and procedures, and care coordination for individuals at risk of suicide.

Congruent with the NPSG and ENA, MEDHOST is committed to finding ways to help hospitals and their clinicians quickly identify at-risk patients. By increasing the understanding, knowledge, and preparedness of ED staff and providers over patient suicide risks, patient identification can become more effective, and resources can be readily provided to improve the safety and quality of care for such individuals.

To support emergency departments in these efforts, MEDHOST Emergency Department Information System (EDIS) allows screening tools to be built into the platform per a facility’s needs, along with custom charting options that can be used to help facilities identify patients at risk for suicide.

To learn more about how MEDHOST EDIS can help run your hospital more efficiently with customizable tools, please reach out to us at or call 1.800.383.6278.

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