Suicide Prevention in Health Care.

Decreasing suicide rates through health care system change is an example of how improving patient safety warrants psychiatrists’ awareness, training, teamwork, and leadership in system-based solutions. It has been over 15 years since the Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System (2), reported that “at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented.” In March of 2001, IOM’s next catalyzing report, Crossing the Quality Chasm, concluded that “merely making incremental improvements in current systems of care will not suffice.” These reports inspired the nation’s campaign to improve quality and safety in health care (3). However, adverse events causing morbidity and mortality continue. The Six Sigma comparison of industries ranks the many health care “defects per million opportunities” near that of the Internal Revenue Service tax advice phone-in service; domestic airline flight fatality rates achieve superior Six Sigma safety rates (4). Many of the country’s top sentinel events are mental health related, including restraint-related events, elopements, selfinflicted injuries, and suicides (5). Some of the top sentinel event settings include psychiatric hospitals, psychiatric units, and behavioral health facilities, totaling 19% of all locations for sentinel events since 2004. In comparison, emergency departments account for only 5.4%, and office-based surgery, 0.9%. Approximately 1,500 inpatient suicides occur per year in theUnited States (6). In juxtaposition, themost recent data from aviation fatalities from theNational Transportation Safety Board reveal a total of only 443 aviation deaths (7). If psychiatrists are the pilots of the mental health system, then what can they do in collaboration with others to transform the industry to the next level of safety at a systems level? Many organizations support this system transformation, including IOM, the Agency for Healthcare Research and Quality, the Joint Commission, the American Academy of Child and Adolescent Psychiatry, and the American Psychiatric Association. In addition, the American Board of Medical Specialties is highlighting safety standards by integrating patient safety principles into its program for maintenance of certification (MOC) requirements (9). The American Board of Psychiatry and Neurology is part of this leadership drive (10). Focus will begin attending to MOC safety requirements and providing a review of current clinical safety practice. Patient safety is a vital function of psychiatric services and a core objective of the mental health system. Without safety, there would be neither treatment nor recovery. Suicide is one of the top safety challenges that our health care system faces. Psychiatrists and other mental health clinicians practice standards of care in their provision of suicide risk assessment, risk management, and biopsychosocial treatments. However, in the system of care some failure modes are root causes of suicide and are beyond the realm of the psychiatrist’s assessment and treatment. If there were board exam questions on suicide data and suicide risk assessment, psychiatrists would readily know the answers (noted at the end of this column):