Death by Suicide Within 1 Week of Hospital Discharge

• DOI: 10.1097/nmd.0000000000000687
• Publication Date: 2017-05-16T16:34:01Z
• Authors: Natalie Riblet; Brian Shiner; Bradley V. Watts; Peter Mills; Brett Rusch; Robin R. Hemphill
• Keywords: Adult; Male; Time Factors; Hospitals, Veterans; Pain; Psychiatric Department, Hospital; Middle Aged; Patient Discharge; United States; 3. Good health; Suicide; United States Department of Veterans Affairs; Young Adult; 03 medical and health sciences; 0302 clinical medicine; Cause of Death; Ill-Housed Persons; Humans; Patient Compliance; Female; Root Cause Analysis; Aged; Retrospective Studies

AbstractThere is a high risk for death by suicide after discharge from an inpatient mental health unit. To better understand system and organizational factors associated with postdischarge suicide, we reviewed root cause analysis reports of suicide within 7 days of discharge from across all Veterans Health Administration inpatient mental health units between 2002 and 2015. There were 141 reports of suicide within 7 days of discharge, and a large proportion (43.3%,n= 61) followed an unplanned discharge. Root causes fell into three major themes including challenges for clinicians and patients after the established process of care, awareness and communication of suicide risk, and flaws in the established process of care. Flaws in the design and execution of processes of care as well as deficits in communication may contribute to postdischarge suicide. Inpatient teams should be aware of the potentially heightened risk for suicide among patients with unplanned discharges.