Care – Suicide / Self-Harm

Service: Risk Management
Subject: Care
Setting: Mental Health
Type: Risk Profiles

Suicidal / self-harm behaviours are complex and multi-factorial, which make them very challenging predictors of future conduct. The care of individuals at risk of suicide can be improved through preventative measures that focus on the essential elements of suicide care for those at risk. This document contains information entered by HIROC Subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Key Controls / Mitigation Strategies

  • Systems, Policies and Procedures:
    • Implementation of clinical guidelines and standardized suicide assessment tool
    • Patient observation algorithm/decision aid 
    • Specific assessments/evaluations to be performed before off-unit privileges/passes are granted
    • Opportunity to review cases on a daily basis through bullet rounds to potentially change observation level or develop a care plan specific to concerns
    • Interprofessional psychiatric service consultations for at risk patients
    • Psychiatric crisis team available 24/7 to the Emergency Department
    • Patients identified in the Emergency Department and referred to crisis are assessed for suicidality, plans and access  
    • Consultation-liaison team consisting of a psychiatrist and nurse who will assess patient on inpatient units other than Mental Health
    • Improving the intake process to ensure referrals are actively triaged for acuity
    • Sitter to be assigned to stay with patient until appropriate transfer to Mental Health
    • Policies and procedures related to constant/close observation; seclusion room protocol; examination of client belongings, suicide prevention
    • All suicide attempts on the unit, on the premises or while a patient was on an approved Leave of Absence are reviewed and the plan of care updated accordingly
    • Interventions to address the client/resident’s risk of elopement, goals to prevent harm to the client and/or third parties (i.e. within client/resident’s care plan)
    • Debriefing and support process for staff when elopement outcome results in unanticipated death or harm of the patient and/or a third party
    • Explore partnerships with community organizations that serve clients with complex needs 
    • Working collaboratively with other community organizations and planning bodies to identify gaps and propose solutions to improve access to appropriate services in a timely manner
    • Suicide Prevention Steering Committee that monitors and identifies and implements best practice
  • Client and Family-Centered Care:
    • Improve office flow and booking practices to maximize use of appointments (i.e., minimizing no-shows through reminder calls, filing cancellations, etc.)
    • Leverage the patient portal for appointments, questions and scheduling contacts for key questions/triage to improve timeliness in responses
    • Offering a "Group Choice Appointment" for those referred to both psychiatry and group therapy to onboard them more quickly
    • Review of unit expectations with patient and family on admission
    • Encourage patient to seek staff if feeling suicidal
  • Space Design and Environmental Safety:
    • Environmental safety assessments are conducted for designated inpatient mental health care units, general medical/surgical units admitting at-risk patients as well as emergency departments
    • Ensure the safety assessment includes a standardized evidence-based safety assessment tool
    • Point of care testing (and documentation) of risk reduction design features (e.g., weight tested breakaway hardware) as well as feedback from interviews with staff and patients
    • Any modifications to the physical environment are reviewed for safety and whether any new fixtures or equipment are ligature and tamper proof
    • Room close to nursing station
    • Safe food trays cutlery
    • Removing personal and unnecessary items from room
    • Controlled access perimeter, doors, elevators, and portals
    • Monitoring patient entry and exit using cameras and remote control of doors to the unit
  • Education and Training:
    • Staff education on assessment and care of the suicidal patient
    • Participate in training opportunities (e.g., eating disorders in youth)
    • Offer Trauma-Informed Care training to all staff
    • Manager on-call protocol is in place for consultation  

Monitoring / Indicators

  • The wait time from time referred to time seen as outcome indicator
  • No-show rate and referral rate monitored as process indicators
  • Tracking of high severity incidents and near misses
  • Critical incidents are reviewed and recommendations identified
  • Frequency and method for reporting safety assessment findings, controls, and recommendations to the organization
  • Reports to leadership on suicide attempts
Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.