Systematic and organizational issues implicated in post-hospitalization suicides of medically hospitalized patients: A study of root-cause analysis reports.

OBJECTIVE

Medical hospitalization is a high risk period for suicide. It is important to understand system-level factors that may be associated with suicide after a medical hospitalization.

METHOD

Retrospective study of root-cause analysis (RCA) reports of suicide occurring within three months of Veterans Administration (VA) medical hospitalization, 2002-2015. We collected patient and system-level factors to characterize events.

RESULTS

There were 96 RCA reports pertaining to suicide within three months of medical hospitalization. A total of 168 root causes for suicide were identified and fell into three major themes including: management of known suicide risk (N=73, 43%), decision making to monitor suicide risk (N=48, 29%), and patient engagement in treatment (N=47, 28%). RCA reports raised concerns that medical teams did not provide mental health treatment when indicated and lacked a standardized process for assessing psychological well-being in patients with a serious medical illness. In 25 cases, patients declined recommended treatment and in 15 cases, patients left against medical advice (AMA).

CONCLUSIONS

Challenges with patient engagement in treatment and lack of standardized processes for assessing and managing suicide risk may play an important role in suicide risk after medical hospitalization. Additional high quality studies are needed to confirm our findings.