Suicide Risk: Navigating the Failure Modes
CASE STUDY: A PATIENT WITH A RECENT SUICIDE ATTEMPT
A 38-year-old podiatrist, well known in his small community, was admitted through the emergency department to a local hospital. He was brought in by the police who discovered him in his crashed car; he had presumably driven the car off a cliff. The patient suffered multiple fractures and injuries for which he was treated in the emergency department. A sister, his closest relative, found a suicide note at his home. She lived approximately 2 hours away. The police were sure this was a serious, but miraculously failed suicide attempt. The patient was transferred to a locked, inpatient psychiatric service where a history was taken.
Much of his childhood history was unremarkable. He had graduated from high school, had completed podiatric medical school, and had set up a practice not far from where he grew up. He was well liked by his patients, had a pleasant manner, and was fairly popular in his community. It emerged during the hospitalization that the patient, who was an avid skier, had stolen expensive ski equipment from several stores, and this had come to the notice of local law enforcement. The patient had ongoing marital conflicts with his wife from whom he was separated. They had three young children who were now with his wife and with whom he had sporadic contact as she lived a few hours away with her parents. His solo practice had declined, and his business was on the brink of ruin.
In the hospital, the patient was placed on observation for ongoing suicidal ideation, severe depression, anhedonia, poor self-care, hopelessness, and tearfulness. Several medications were tried without much improvement. He was then given ECT [electroconvulsive therapy] with good results. Gradually, he began to improve, was more engageable, and attended groups but was not always forthcoming about his concerns. He continued to be anxious and did not always sleep well. The patient was transferred to an open ward with no privilege restrictions, and his treatment with a SNRI [serotonin-norepinephrine reuptake inhibitor] continued. His sister visited him on and off. The nurses tried to mobilize the patient toward establishing life goals, but he had a hard time focusing. At least three psychiatrists treated the patient, making notes that were hard to interpret in the chart. It was unclear from the chart review whether they were members of the same practice or whether they had spoken to one another about the patient.
The patient learned that the police had charged him; he was awaiting a hearing. He also heard that his wife now wanted a divorce and wanted full custody of their children. He spoke to the treatment team and asked the social worker to contact his sister. He told his sister that he wanted her to handle all his affairs and prepared a note to that effect. He remained on an open unit without observation but was still on 15-minute checks. Early one morning soon after he saw his sister, the patient was found hanging from a makeshift hook in the bathroom of his room. On the 15-minute checks the previous night, the nurse had thought he was in bed. He had placed pillows under the sheets, deceiving the nurse into thinking he was in bed. The family, colleagues, and staff were devastated. Clinicians asked themselves: “What did I miss? Could I have prevented this? Does this mean I am not a good psychiatrist? Will I be sued?
WHAT ARE WE UP AGAINST?
In the words of Robert I. Simon, M.D. “There are two kinds of psychiatrists: those who have had patients commit suicide and those who will” (1). Suicide is a high-risk, yet relatively low-frequency event that we are not good at predicting (2). There are more than 30,000 suicides per year in the United States (3). Of these, 5%–6% occur in hospitals (3), translating to nearly 1,800 inpatient suicides per year. Suicide had been the number one Joint Commission Sentinel Event in our nation in 2005 (4). Suicide as a hospital sentinel event was more common than operative and postoperative complications, more common than wrong-site surgeries, and more common than medication errors. It is now the fifth most frequently reported sentinel event by The Joint Commission (Sentinel Event Statistics 2004–2010). (5) Suicide is the number one cause of psychiatric malpractice settlements and verdicts (6). It was the fifth most frequently reported Sentinel Event by The Joint Commission (Sentinel Event Statistics 2004–2010).
Psychiatrists and organizations cannot expect to wait for the suicides or lawsuits to occur to realize opportunities for change and improvement. There will be mistakes despite good psychiatrists practicing within good systems of care. Barriers exist for individual clinicians within themselves, their treatment teams, their organizations, and mental health systems, creating failure modes affecting suicide risk assessment and risk reduction.
WHAT ARE THE BARRIERS TO OVERCOME?
Failures can and do occur in systems of care. Failure modes are problems that might occur at various levels in the risk assessment, management, and treatment of a person at risk and result in a suicide. A failure mode and effect analysis (FMEA) is a prospective analysis of the entire system and process of suicide risk assessment and management that assesses where high-risk problems might occur. The final goal of an FMEA is to then mitigate or, if possible, eliminate the failure points to change the process, design, or system to support improved care and safety for the patient and improved success for the clinician. Failure modes can be extrapolated from the realm of common allegations of negligence, as summarized by Scott and colleagues' (6) (Table 1).
Reproduced with permission from Simon RI, Hales RE (eds): Textbook of Suicide Assessment and Management. Arlington, VA, American Psychiatric Publishing, Inc., 2006.
Failures of the system can be organized across a spectrum of eight areas, ranging from the quality of the suicide risk assessment to appropriate training and orientation. In each of the eight areas of failure modes, the subsequent solutions can be viewed through multiple lenses, including the scope of 1) the individual clinician, 2) the team, 3) the organization, and 4) the entire system. Table 2 summarizes the failure modes and some of the strategies to overcome barriers to effective suicide risk assessment and risk reduction (7–13).
* Scope of 1) the individual clinician, 2) the team, 3) the organization, and 4) the entire system.
Is “NO SI (suicidal ideation)” a good enough suicide risk assessment?
In the study of Busch et al. (3) of patients who committed suicide while inpatients or immediately after discharge, 78% denied suicidal ideation at their last communication. The greatest clinical root cause of inpatient suicide is a failure in clinical assessment (Figure 1). Reported suicides have increased by 20% from 2005 to 2008.
Figure 1. Root Causes of Inpatient Suicides (1995–2005).
[Reproduced with permission from JCAHO sentinel event data (11).]
Clinicians are not able to predict suicide. However, psychiatric standard of care requires a suicide risk assessment (6). Suicide risk assessment should entail the following five elements:
1.
Suicide Risk Factor Assessment. The formation of a therapeutic relationship with the patient provides a foundation for a complete interview. A review of all possible resources, ranging from contact with family to contact with care providers to review of records, is also essential. In the case presented above, several psychiatrists treated the patient. There was no evidence in the record of communications among them and no identification of risk factors or risk reduction factors. [Potential failure modes in the case of the podiatrist are identified in italics.] Failure to pursue a review of resources has been grounds for successful malpractice claims. From the patient interview and information from all possible resources, the suicide risk assessment should 1) elicit suicidality and 2) elicit the dynamic and static risk factors and risk reduction factors. Individual risk factors and protective factors are important to obtain and include in assessment. The patient has experienced numerous losses—his practice, his wife and children, and his reputation; he had made a near-fatal, serious suicide attempt before hospitalization. He had left a suicide note. Although he was slowly responding to medications, his problems were only compounded later in his stay by the police notification. In more restrictive settings, the risk of elopement should be assessed simultaneously, given that successful suicides have been associated with elopement. If the patient can be served in a less restrictive setting, assessment of the patient's capacity to implement a treatment plan will be important. A brief outline of some of the risk factors and risk reduction factors is presented in Table 3.
Another strategy to recall risk factors is “The Dozen A's of Suicide Risk” (13) presented in Table 4.
Multiple resources, which provide a more complete listing of the risk factors and risk reduction factors exist; the use of 15-minute checks must be avoided in seriously suicidal patients (13). In addition to interviewing approaches to elicit suicidality and the risk factors (14–20), resources are also available for work with special populations, e.g., children and adolescents (21, 22) and the elderly (6), for work in special settings, including jails and prisons, (23–25), and for cultural competence with various ethnic groups (6).
2.
Formulation. On the basis of the suicide risk assessment, the psychiatrist formulates the information into a coherent, clinically based assessment, including estimation of risk. Although suicide assessment measures may be used as an adjunct to the clinical interview (26), no formal suicide risk assessment measure presently has predictive value by itself for individual patients (6). The artful and skilled formulation by the clinician is the key and resources to provide guidance in regard to suicide risk formulation exist (27).
3.
Safety Management and Treatment Plan. The suicide risk assessment and formulation will drive the treatment plan. Choices of level of care and 1:1 suicide precautions will be based on estimation of risk. Treatment plans should address mitigation of dynamic risk factors and strengthening of the risk reduction factors. Biological therapies (2, 6) and psychosocial treatments (2, 27), including cognitive therapy (28), have been shown to decrease suicide risk. In the case example above, the patient had not formed a therapeutic relationship with his doctors. He asked to hand over assets to his sister and seemed calm after he did so—this should have alerted his care providers. He had been unable to sleep and was noted to be anxious. These are key factors to be managed.
4.
Crisis Plan. Not only has a review of the published literature shown that approximately 41% of persons who died from suicide had contact with inpatient care within 1 year, up to 9% of those completed suicide within 1 day of discharge from inpatient care. For community-based psychiatric care, 11% of persons who completed suicide made contact within 1 year and 4% within 1 day (27). Development and implementation of a crisis plan, which takes a relapse prevention approach with the patient and other persons in the system to monitor for and prevent antecedents for relapse and implement response strategies for relapse, can be an indispensable safety net and operational component of recovery. Table 5 provides a summary of some key elements in the relapse prevention plan. Crisis plans can also be a component of a person's recovery and be operationalized as a component of a psychiatric advanced directive and a wellness recovery action plan.
5.
Suicide Risk Reassessment (especially during high-risk periods). Suicide risk reassessment should occur at high-risk transitions for the patient. These transitions should be individualized on the basis of the patient's clinical situation—e.g., after a stressful telephone call, at a time of loss, or at times known to be high risk from the literature (Table 2) such as step down from intense observation, transfers between units of service, and after discharge. The most common locations for suicide are bathrooms, followed in frequency by the individual's room (18). This step was clearly not done with the patient in the case example.
Information from reference 12.
Barriers to improved patient safety in regard to suicide also exist beyond the scale of the psychiatrist into the regions of the team, organization, and system (Table 2).
CONCLUSION
Evidence supports the fact that psychiatrists are not able to predict suicide (2). However, suicide risk assessment and risk reduction are attainable. The right skill, teamwork, and system support minimize the risk for the patient and physician. With the failure modes for suicide being addressed, the case of the podiatrist presented here might have had a different outcome. Awareness of the barriers to safe patient care is the first step toward improving suicide risk. Once identified, means to overcome these barriers can be put in place. Psychiatrists can be more confident in suicide risk assessment and reduction, thereby improving patient safety.
TAKE HOME POINTS
•.
Document your thinking, assessment, and plan.
•.
Suicide prediction is not the standard; suicide risk assessment is the standard.
•.
Suicide risk assessment entails a) eliciting patient's suicidality and risk factors and risk reduction factors and b) pursuing and reviewing all available resources from records to colleagues' family.
•.
Formulation is
—a balancing of the clinical detail, ranging from the patient's suicidality to record review to eliciting the patient's suicide risk factors and protective factors;
—systematic and disciplined;
—a reasoned and inductive process, which drives treatment planning; and
—not a prediction, guess, or intuition.
•.
Estimate risk for the near future.
•.
Build a therapeutic alliance with the patient and family, supporting hope and recovery.
•.
Maintain awareness of countertransference issues and manage.
•.
Do not rely on safety/suicide contracts.
•.
Consider consults and second opinions.
•.
Management and treatment are driven by the suicide risk assessment, targeting decreasing dynamic suicide risk factors and strengthening dynamic risk reduction factors.
•.
Reassess suicide risk—especially at high-risk times—e.g., admission, discontinuation of 1:1 precautions, times of psychosocial change for the patient, before passes and discharge, before termination, and at other transition points.
•.
Develop a relapse prevention plan to help mitigate relapse of suicide risk.
•.
Support open teamwork and communication with colleagues in a setting of mutual respect and structured hand-off communication.
•.
Work in a setting with
—appropriate resources and staffing, including safe and secure environments of care and skilled orientation and training and
—system structure and procedural guidelines to overcome failure modes and support successfully psychiatric services.
REFERENCES
1.
Simon RI: Suicide risk assessment: what is the standard of care? J Am Acad Psychiatry Law 2002; 30:340–344
2.
American Psychiatric Association: APA Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. Am J Psychiatry 2003; 160(11 suppl):1–60
3.
Busch KA, Fawcett J, Jacobs DG: Clinical correlates of inpatient suicide. J Clin Psychiatry 2003; 64:14–19
4.
Joint Commission on Accreditation of Healthcare Organizations: Sentinel event statistics: as of December 31, 2005. http://www.jointcommission.org/NR/rdonlyres/6FBAF4C1–F90E-410C–8C1D–5DA5A64F9B30/0/se_stats_1231.pdf
5.
The Joint Commission: Summary Data of Sentinel Events Reviewed by The Joint Commission, 2011. http://www.jointcommission.org/assets/1/18/SE_Data_Summary_4Q_2010_(v2).pdf
6.
Scott CL, Resnick PJ: Patient suicide and litigation, in Textbook of Suicide Assessment and Management. Edited by Simon RI, Hales RE. Arlington, VA, American Psychiatric Publishing, Inc., 2006, pp 530–531
7.
Silverman MM, Berman AL, Bongar B, Litman RE, Maris RW: Inpatient standards of care and the suicidal patient. Part II: an integration with clinical risk management. Suicide Life Threat Behav 1994; 24:152–169
8.
Torrey WC, Drake RE, Dixon L, Burns BJ, Flynn L, Rush AJ, Clark RE, Klatzker D: Implementing evidence-based practices for persons with severe mental illness. Psychiatr Serv 2001; 52:45–50
9.
Drake RE, Goldman HH, Leff HS, Lehman AF, Dixon L, Mueser KT, Torrey WC: Implementing evidence-based practices for persons with severe mental illness. Psychiatr Serv 2001; 52:179–182
10.
National Patient Safety Goals: Improve Communication, Requirement, Applies to Ambulatory Care, Assisted Living, Behavioral Health Care, Critical Access Hospitals, Disease Specific Care, Home Care, Hospitals, Laboratories, Long Term Care, Office Based Surgery. Oakbrook, IL, Joint Commission on Accreditation of Healthcare Organizations 2011. http://www.jointcommission.org/standards_information/npsgs.aspx
11.
McGreevey M (ed): Reducing the Risk of Suicide. Oakbrook, IL, Joint Commission on Accreditation of Healthcare Organizations, 2005, p 13–14
12.
Joint Commission on Accreditation of Healthcare Organizations: JCAHO sentinel event data, root causes of inpatient suicides 1995–2005. http://www.jcaho.org/accredited+organizations/ambulatory+care/sentinel+events/rc+inpatient+suicides.htm
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Jayaram G, Sporney H, Perticone P: The utility of 15 minute checks in inpatient settings and its effectiveness. Psychiatry (Edgmont) 2010; 7:46–49
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Hayes LM: Prison Suicide: An Overview and Guide to Prevention. U.S. Department of Justice, National Institute of Corrections, June 1995. http://www.nicic.org/pubs/1995/012475.pdf
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Brown GK: A Review of Suicide Assessment Measures for Intervention Research with Adults and Older Adults. Bethesda, MD, National Institute of Mental Health, 2000
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28.
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Information & Authors
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Published online: 1 April 2011
Published in print: Spring 2011
Authors
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CME Disclosure
Yad M. Jabbarpour, M.D., Clinical Assistant Professor, University of Virginia School of Medicine, Catawba, VA.
Reports no competing interests.
Geetha Jayaram, M.D., M.B.A., Associate Professor, Departments of Psychiatry and Health Policy and Management, Johns Hopkins School of Medicine, Baltimore, MD.
Advisory Board. Janssen
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