Behavioral healthcare organizations nationwide continue to work diligently on implementing TJC’s National Patient Safety Goal on Suicide Prevention. The latest Joint Commission sentinel event data (including suicides) recently became available. So, now is an opportune time to review this data and get an update on this important topic.
Joint Commission Sentinel Event Definition
TJC’s definition of a sentinel event is “a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm (regardless of the severity of harm) or severe harm (regardless of duration of harm.”)
TJC also considers the following to be sentinel events:
- Suicide of any patient in a staffed around-the clock care setting or within 72 hours of discharge, including from the health care organization’s emergency department (ED)
- Homicide of any patient while on site at the organization or while under the care or supervision of the organization
- Homicide of a staff member, licensed independent practitioner (LIP), visitor, or vendor while on site at the organization or while providing care or supervision to patients
- Sexual abuse/assault of any patient while on site at the organization or while under the care or supervision of the organization
- Sexual abuse/assault of a staff member, LIP, visitor, or vendor while on site at the organization or while providing care or supervision to patients
- Physical assault (leading to death, permanent harm, or severe harm) of any patient while on site at the organization or while under the care or supervision of the organization
- Physical assault (leading to death, permanent harm, or severe harm) of a staff member, LIP, visitor, or vendor while on site at the organization or while providing care or supervision to patients
- Abduction of any patient receiving care, treatment, and services
- Any elopement (i.e. unauthorized departure) of a patient from a staffed around the-clock care setting (including the ED) leading to death, permanent harm, or severe harm to the patient
Keep in mind that reporting sentinel events to TJC is still voluntary. Indeed, the estimate is that less than 2% of all sentinel events are reported to TJC.
Also, be aware that certain types of falls now qualify as sentinel events. See our post Falls now Included as Sentinel Events.
Joint Commission Sentinel Event Data
TJC recently updated its sentinel event database to include the first six months of 2022. There were 26 suicides reported during this period. In comparison, there were 79 reported for the full year of 2021.
For the first six months of 2022, data re suicides by setting isn’t available. However, for 2021, the breakdown was as follows: 42 occurred offsite within 72 hours of discharge; 36 occurred on inpatient; 1 occurred in an Emergency Department.
TJC’s data re reported suicides over the last five years (2018 – 2022) shows the following:
Suicide by Setting: The majority occurred offsite within 72 hours of discharge. Next most common setting was inpatient. Last was the Emergency Department.
Leading Methods of Suicide: The leading method of suicide was by hanging. The second leading method was by asphyxiation (other than hanging). Next was by gunshot and last by jumping from a height.
(By comparison, when suicides occur in non-healthcare settings, the leading method is by firearm which has a 90% fatality rate. The second leading method is by hanging.)
Leading Causes: Based on results of root cause analyses (RCAs) the leading root causes contributing to suicide in healthcare settings were as follows:
- Inadequate staff to staff communication during handoffs and transitions of care
- Inadequate staff to staff communication of critical information
- Inadequate communication with outside providers during transitions of care
- Not adequately following policies
- Inadequate suicide risk assessment
As we work with clients on implementing NPSG 15 for Suicide Prevention, these are also the common challenging areas that we identify.
As noted, reporting sentinel events to TJC is voluntary. However, as an accredited organization, you must complete an RCA – even if you don’t report the event to TJC. In addition, you must develop a corrective action plan, implement the plan, and monitor its effectiveness.
In our work with organizations over the years, we’ve found that RCAs can be hugely beneficial. When thoughtfully conducted, they identify process breakdowns and help develop strategies for preventing similar events in the future.
The Institute for Healthcare Improvement has an excellent RCA tool that TJC also endorses. It’s called RCA2: Improving RCAs and Actions to Prevent Harm. It provides tools and methods for conducting effective RCAs.
TJC’s Sentinel Event page has some excellent resources re sentinel events and RCAs. Be sure to check it out.
For more information and strategies for compliance with NPSG 15 on Suicide Prevention, see our earlier posts:
- NPSG 15 Suicide Prevention: Training & Competency Requirements
- NPSG 15 Suicide Prevention: The Monitoring Requirement
- NPSG 15 Suicide Risk Reduction: Feedback from the Field
- Suicide Risk Assessment: Q&A on July 1 Revisions to NPSG 15.01.01
- NPSG.15.01.01 Suicide Risk Reduction: Monitoring High Risk Patients
- NPSG.15.01.01 Suicide Risk Reduction: Safety Planning at Discharge
Barrins & Associates Consultation
In addition to our mock surveys, we’ve assisted many clients with conducting their RCAs in follow-up to a sentinel event. We have tools we use for that process and clients often find it helpful to have an objective party involved in that important endeavor.