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

The Journal of Nervous and Mental Disease
Natalie RibletRobin R Hemphill

Abstract

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.

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Citations

Jul 19, 2018·Psycho-oncology·Maya AboumradBradley V Watts
Jan 24, 2020·Clinical Gerontologist·Michele J KarelMarsden H McGuire
Jun 3, 2020·International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care·Marianne WyderDavid Crompton
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Mar 12, 2019·Archives of Suicide Research : Official Journal of the International Academy for Suicide Research·Laurent MichaudCéline Bourquin
Jun 26, 2020·Frontiers in Psychiatry·Lana BojanićPauline Turnbull
Feb 2, 2021·Administration and Policy in Mental Health·Bridget B MatarazzoLisa A Brenner
Nov 7, 2019·The Journal of Nervous and Mental Disease·Natalie B RibletBradley V Watts
Jun 10, 2021·Psychiatric Services : a Journal of the American Psychiatric Association·Eric M SchmidtJodie Trafton

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