Thursday, July 22, 2004
9:30 AM - 10:00 AM
Thursday, July 22, 2004
2:30 PM - 3:00 PM
This presentation is part of : Posters I
Root Cause Analyses Lessons Learned: Innovative Strategies to Minimize Suicidal Indication Risk in Hospital and Ambulatory Mental Health Settings
Bridget Maybury, RN, MSN, ANP, Director's Office, Bronx Veteran's Affair Medical Center, Bronx, NY, USA, Lynda Olender, RN, ANP, CNAA, Director's Office, Veterans Affair Medical center, Bronx, NY, USA, Mary Sullivan, MSN, RNC, CARN, Carl T. Hayden VA Medical Center, Department of Veterans Affairs, Phoenix, AZ, USA, and Janet Barber, MSN, RN, USAF, (Ret), Clinical Nurse Consultant, Hill-Rom, Batesville, IN, USA.
Learning Objective #1: n/a
Learning Objective #2: n/a

Objectives: The learner will be able to: · State the rationale for the importance of developing strategies for suicide prevention. · Identify innovative strategies gained from Root Cause Analyses (RCA) reviews for the prevention of suicide in both acute inpatient and ambulatory mental health settings.

Rationale: The U.S. National Institutes Mental Health data (2000) reflects that suicide is the eleventh leading cause of death in the U.S the 8th leading cause of death for males, and the 19th cause of death for females. Additionally the total number of suicide deaths was 29,350 with suicides far outnumbering homicides at 16,765. Additionally, it is estimated that there are 8-25 attempted suicides to one completion with the ratio higher in women and youth and lower in men and in elderly populations. It is also estimated that more women than men report a history of attempted suicide, with a gender ratio of 3:1.

Hospital Approach: Root cause analyses were performed for all para-suicidal events occurring either within an acute or ambulatory care setting over a two-year timeframe. A review of these RCA’s lead to MEASURABLE strategies to minimize suicidal risk as follows: increasing visibility of leadership by regular rounding addressing patient safety issues; development of a computerized suicide assessment template’ new guidelines for rotation of psychiatry residents “changeovers”; sign out mechanisms between each attending physician; redesign of the nursing delivery model; flow sheets to track linen discrepancies; use of a hand-scanner with search policy; proactive approach to discharge plan assessing suicidal risk re: the impact of discharge; and finally, enhancing educational initiatives re: interviewing skills, case study and morbidity and mortality conferences.

Summary: Implementation of strategies derived from the analyses of RCA can decrease the risk factors for suicide. Additionally, monitoring of related outcomes can prove to be an invaluable and perhaps life-saving measure.

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Sigma Theta Tau International
July 22-24, 2004