Inpatient Suicide Prevention

A Review of the Patient Safety Authority’s Keys to Ligature Risk Assessment Project

  • Christopher Mamrol Patient Safety Authority
  • Melanie A. Motts Patient Safety Authority
  • Richard Kundravi Patient Safety Authority

Abstract

It takes less than five minutes and 18 inches from the ground for a person to self-asphyxiate from hanging.1 According to the American Foundation for Suicide Prevention (AFSP), suicide is currently the 10th leading cause of death in the United States and 11th in Pennsylvania.2 Of those deaths, hanging from a ligature point is the most common method of suicide in inpatient healthcare facilities. It should be no surprise that the plethora of ligature points in hospitals is a major patient safety concern. For these reasons, the Patient Safety Authority (PSA) launched a project in July 2018 with the aim to assist Pennsylvania facilities in identifying and mitigating ligature risks.

 

Author Biographies

Christopher Mamrol, Patient Safety Authority

Christopher Mamrol (cmamrol@pa.gov) is a senior patient safety liaison with the Patient Safety Authority for the Southeast region of Pennsylvania. Prior to joining the PSA, he worked at Montgomery County Emergency Services, Inc., serving in multiple roles, including as a psychiatric technician, registered nurse, risk manager/patient safety officer, performance improvement director, and Safety and Quality Systems director.

Melanie A. Motts, Patient Safety Authority

Melanie A. Motts is a senior patient safety liaison with the Patient Safety Authority for the Eastern region of Pennsylvania. Previously she worked in outpatient and inpatient settings as a manager, educator, and registered nurse. As director of nursing and a patient safety officer for an acute care hospital in the Lehigh Valley, she led a team of nursing staff, case managers, laboratory staff, and clerical support, which earned the CMS 5-star rating for quality of care provided and patient satisfaction.

Richard Kundravi, Patient Safety Authority

Richard Kundravi is a patient safety liaison with the Patient Safety Authority for the Northwest region of Pennsylvania. Prior to coming to the PSA, he served as the director of Risk Management and Patient Safety at UPMC McKeesport as well as the facility’s corporate compliance officer, privacy officer, director of peer review, and patient representative.

References

Knoll JL. Inpatient suicide: identifying vulnerability in the hospital setting. Psychiatric Times. 2013 May;30(6):36.

Suicide Statistics [Internet]. New York: American Foundation for Sui-cide Prevention; 2018 [cited 2019 Jul 15]. Available from: https://afsp. org/about-suicide/suicide-statistics/.

Clarification of Ligature Risk Interpretive Guidelines [Internet]. Revi-sions to State Operations Manual (SOM) Chapter 2 Certification Process and Appendix A Hospitals. Baltimore: Department of Health & Human Services, Centers for Medicare & Medicaid Services; 2019 [cited 2019 Aug 5]. Available from: https://www.cms.gov/Medicare/Provider-Enroll-ment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-19-12-Hospitals.pdf

Hunt JM, Sine DM, McMurray KN. [Internet]. Behavioral Health Design Guide. [cited 2019 Aug 5]. Available from: http://www.bhfcllc.com/wp-content/uploads/2019/06/Design-Guide-8.1-web.pdf

Shepard DS, Gurewich D, Lwin AK, Reed GA Jr, Silverman MM. Suicide and suicidal attempts in the United States: costs and policy implica-tions. Suicide Life Threat Behav. 2016 Jun;46(3):352-62.

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Published
2019-12-17
How to Cite
Mamrol, C., Motts, M. A., & Kundravi, R. (2019). Inpatient Suicide Prevention: A Review of the Patient Safety Authority’s Keys to Ligature Risk Assessment Project. Patient Safety , 1(2), 8. https://doi.org/10.33940/behavhealth/2019.12.8
Section
Patient Safety Initiatives
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