PMID: 16617944Apr 19, 2006Paper

Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration

Joint Commission Journal on Quality and Patient Safety
Peter D MillsKierston Howard

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 s...Continue Reading

References

Jul 1, 1997·Journal of Mental Health Administration·M T Lambert, D R Fowler
Oct 27, 2005·JAMA : the Journal of the American Medical Association·J John MannHerbert Hendin

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Citations

Apr 2, 2015·Quality Management in Health Care·Alok MadanJ Christopher Fowler
Dec 13, 2016·BMJ Quality & Safety·Kathryn M KelloggRollin J Fairbanks
Nov 9, 2007·The Journal of Behavioral Health Services & Research·Mayur M DesaiRani A Desai
Nov 9, 2011·Journal for Healthcare Quality : Official Publication of the National Association for Healthcare Quality·Rustin B Morse, Murray M Pollack
Jun 25, 2016·BMJ Quality & Safety·Mohammad Farhad PeerallyMary Dixon-Woods
Apr 22, 2018·World Journal of Pediatrics : WJP·Timothy R RiceLeo Sher
Aug 2, 2012·International Journal of Environmental Research and Public Health·Vsevolod Rozanov, Vladimir Carli
Feb 24, 2012·Journal of Healthcare Risk Management : the Journal of the American Society for Healthcare Risk Management·Alan J CardP John Clarkson
Oct 1, 2013·Journal of Healthcare Risk Management : the Journal of the American Society for Healthcare Risk Management·A Zachary HettingerRobert L Wears
Feb 24, 2017·BMJ Quality & Safety·Patricia Trbovich, Kaveh G Shojania
Nov 11, 2021·Suicide & Life-threatening Behavior·Alta du PontMark A Reger

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