Establishment of a Comprehensive Inpatient Suicide Prevention Network by Using Health Care Failure Mode and Effect Analysis

To address incomplete screening and its potential causes, we implemented an integrated electronic medical system. The IT crew added a required field regarding “TDQ scoring” in the nursing evaluation entry. With the new system, nurses complete a screening procedure within 24 hours of admission of a new patient in one or more of the four risk categories described above and use the required field to record the results.

We visited every medical and surgical ward to educate nursing staff to recognize the necessity for inpatient suicide prevention and to use the TDQ correctly. New staff training and continuing education regarding inpatient suicide were arranged annually. All hospital staff were invited and empowered to be gatekeepers of inpatient suicide prevention.

Because all HFMEA team members recognized the importance of recording TDQ truthfully and informing the in-charge and on-duty physicians about the patient’s suicide risk, we updated the computerized physician order entry (CPOE) procedure to reduce misses and errors. If a nurse recorded a TDQ score of more than 12, it would elicit an alert indicating that a psychiatric consultation was recommended. This message was automatically inserted into the CPOE of the in-charge and on-duty physicians.

We transferred at-risk patients to rooms near the nursing stations and ensured that patients were monitored during duty shift changes. Room inspections were performed to ensure inpatient safety and limit access to tools that could assist in a suicide attempt (e.g., curtain rope). Education was offered to caregivers and family members who continually visited the patients. If an immediate suicide risk remained, a transfer to the acute psychiatric ward for further intense treatment was recommended, once the patient’s physical condition stabilized.

After in-charge physicians received an alert, they could decide not to consult a psychiatrist because of incompatible opinions regarding the patient’s suicide risk or possibly neglect to request a consultation because of the stigmatization of mental illness. Furthermore, the patients or their families could refuse referral. Therefore, we designed a mandatory field—“Why no consultation?”—that appeared before physicians closed the message window in the CPOE. The results were collected and sent to the social worker on a monthly basis for analysis and evaluation. The most common answer was, “This patient is not appropriate for psychiatric consultation after evaluation.” We also attempted to engage with specific physicians who exhibited a rigid or passive attitude toward suicide prevention. When the in-charge team decided to request a consultation, a formal consultation liaison record with a thorough evaluation and recommendations was entered into our integrated medical system. All psychiatrists who provided consultation services were required to select whether the patient was at high or low risk of suicide. If the patient was at high risk, the psychiatrist would offer suggestions—which included default options such as transfer to a psychiatric service, requirement of 24-hour family accompaniment, or transfer to a bed near the nursing station—by clicking the options in the CPOE before a formal consultation form was completed.

Even if the screening process ran smoothly, we still required a mental health professional to follow up with patients at long-term risk and to perform psychosocial intervention. Therefore, the E-Da suicide prevention center was established as a special administrative unit, and a full-time clinical psychologist was recruited to assist the social worker. Routine inpatient suicide prevention case management was performed by our full-time staffs, even after discharge. Case managers negotiated not only with psychiatrists but also with other medical staff. A 24-hour helpline, which connected to managers, was offered to inpatients and staff at the hospital.