For years, facilities operated by the Department of Veteran’s Affairs have seen an epidemic of inpatient suicides. Over the last decade, an initiative taken to address suicide risks in patients’ physical environments has done a great deal to curtail that danger.

The VA is leading the way for civilian facilities in many different ways and I commend them for doing so. I hope the new commander-in-chief will keep up the good work—I am optimistic.  Patient safety starts with excellent leadership—that means from the very top.

Introduced in 2007, an “environmental checklist” was meant to help secure safer surroundings for those veterans placed in inpatient care to help curb the persistent suicide epidemic. The “checklist” has 114 items for VA hospitals and inpatient centers to tick off when identifying environmental risks that would pose opportunities for an attempt to complete a suicide. Items such as hooks, clothing rods in closets, door knobs and electrical sockets can be more than part of standard furnishing in a patients’ room; they can pose a deadly opportunity for veterans already at risk to act on ideations.  If the patient is psychotic, the patient must be observed line of sight or one to one. If not the patient can stuff food, clothing, toilet paper, or anything down his or her throat.

Thankfully, more than 150 VA hospitals have sought to implement the checklist; installing shelving and cubbies that lack sharp edges, removing hooks from walls and backs of doors, and moving towards making electrical outlets tamper proof. Eliminating these physical hazards takes stress off of hospital staff and allows them to focus on direct patient care; checking on the patients more frequently and receiving more elaborate training on how to identify, care for, and report patients at a risk for suicide. With the high turnover of staff and without the physical change of the patients’ environment, some precautions might be overlooked. Dr. Vince Watts, leader of a study on the checklist, commented that “hardwiring” changes into the facilities means that new or rotating staff couldn’t be forgetful regarding modifications.

Thankfully, the program seems to have had some success. During the duration of Dr. Watt’s study, the average length of stay in VA mental health facilities dropped from 11 days to around 7 days.

Has this method made a significant impact on veteran suicides?

While completed suicides among veterans remain far too prevalent in our society, the evidence shows that this is beginning to change. Prior to the checklist being implemented, the National Center for Patient Safety’s database reported a rate of 4.2 suicides per 100,000 admissions. Without such precautionary measures such as the checklist system in place, every patient could be one step away from taking their life. After the checklist was put into place, the suicide rate plummeted to 0.74 suicides per 100,000 admissions, showing that there is hope for the mental health care that our veterans deserve after their dedicated service.  However environment of care is just one part of the triad to protect patients: the other two parts are proper observation levels and medication.

The risk of suicide for veterans is currently 21% higher than the civilian population, but preventative measures are steadily helping to decrease that number. Crisis lines are actively hiring new responders and putting them through extensive training to properly handle the calls and issues they will face, measures to identify high risk veterans are being taken so a crisis can be stopped before it even takes place.

The VA’s example shows that something as seemingly trivial as a checklist for inpatient facilities to follow can save lives, and civilian hospitals ought to follow suit. By removing physical dangers from a patients’ presence and replacing them with more continuous, educated and accessible care, we can hope to see more lives continue and zero end too soon.

Inpatient psychiatric care is supposed to keep patients at acute risk of suicide safe and provide them with the assessment and standard of care they need to recover. But often, the nurses responsible for caring for these patients lack the training and proper experience needed to prevent suicide.  Hospital leaders, including all physicians, must ensure all staff—including psychiatric nurses– are trained and properly supervised to protect patients from injury or death. Sadly some hospitals put profits before safety and training takes from the bottom line.  Nurses, who believe they are not competent to protect patients must obtain proper training to become competent and not attend to patients until they are properly trained.

According to a report published in the Journal of the American Psychiatric Nurses Association, there are no standard competencies for assessing and managing the suicide risk for psychiatric mental health (PMH) nurse generalists – even though the majority work with acutely suicidal patients in inpatient psychiatric settings.

The language used in this report is chilling for anyone with an interest in the well-being of patients at risk of suicide. The APNA’s report indicated there are “serious gaps in nursing education” in suicide risk assessment, prevention and intervention, and there are “no developed structures and processes” for these generalist nurses who provide care and treatment to patients at risk of suicide.  Hospitals, to their detriment, are often relying on nursing schools to properly train nursing students on patient safety as it relates to suicide prevention.  The nursing schools don’t know what they don’t know about patient safety for suicidal patients. Consequently nursing students are being graduated not equipped for their duties in psychiatric hospitals.  Furthermore licensing boards are not properly testing nurses for suicide prevention in hospitals.

Other care providers in these same inpatient settings, such as most psychiatrists and some—but few– mental health clinicians, have specific training in suicide prevention. But because generalist nurses have, according to the APNA report, “the greatest contact with suicidal patients,” their lack of training exposes these patients to significant risk. The warning signs of suicide are often subtle and intermittent, and they can easily be overlooked by a psychiatrist or clinician who spends limited time with the patient. Meanwhile, the nurses who provide at-risk patients with direct care rarely understand how to recognize those warning signs – or how to appropriately intervene.  Most inpatient nurses do not know that death by hanging is the number one way patients die in psychiatric hospitals; nor do they know that patients will have irreversible brain damage in just a few minutes when brains are deprived of oxygen by hanging.  If nurses knew these facts they would resist any physician order requiring a suicidal patient to be watched only every 15 minutes.

Psychiatric nurses themselves identify a significant risk to patients

Perhaps most concerning of all, these PMH generalist nurses have self-identified the issue as being dangerously unprepared to work with suicidal patients. In one study cited in the APNA report, not one of the PMH nurses interviewed believed they were adequately educated to work with suicidal individuals. Most stated that they felt a “sense of inadequacy” when caring for patients at substantive risk of suicide – and those feelings of inadequacy could well cause those nurses to fail to intervene at critical moments.

Yet despite these significant warning signs, too many inpatient care facilities throw these generalist nurses, who will work with their most vulnerable patients, into a so-called “baptism by fire.” They are expected to learn on the job with little continuing education or support – and that dangerously inadequate level of care puts their patients at extreme risk of dying by suicide.

Fortunately, the APNA has stated that it will take steps to train psychiatric nurses in suicide assessment, prevention and intervention to provide a higher standard of care to future patients. However, inpatient care facilities are responsible for the safety of their patients. When patients at acute risk of suicide come to inpatient care, their care cannot be left in the hands of medical professionals not adequately trained in suicide prevention. And when patients die by suicide after not receiving adequate care, those negligent inpatient facilities must be held accountable.

Deaths by suicide can be prevented when services are in place

According to The Department of Health and Human services, a staggering 55% of counties across the US do not have a single psychiatrist, psychologist or social worker. Incredibly, every one of those counties is rural. That means that for a person who is living in one of these areas who is at a high risk of suicide, a visit to the closest psychiatrist’s office to get the help they need requires hours of travel and missing up to a day of work, something that may not be possible.

According to a recent New York Times article, the isolation and loneliness that can come from living in a rural town, combined with lower income, health problems and family issues can have a negative impact on any resident. For those who are at risk of suicide, that impact could be much greater, especially when the help they need is hours away. Some posit that this isolation could be one reason for the increase of suicides in rural areas over the last few years.

Stigma associated with mental health puts patients at risk

There is still a great deal of stigma associated with seeking help from a mental health professional, so much so that some people who need help actively won’t seek it for fear of  being seen coming or going from a psychiatrist’s office. This stigma is especially strong in rural areas, where the perception is that there is little expectation of privacy.

When there aren’t any dedicated mental health professionals in their area, a person may try to find help through other means. Some rely on friends or family members. Others may turn to drugs and alcohol. But many who need help seek it from their primary care doctors, whom they know and are comfortable with. According to a 2002 analysis published in the American Journal of Psychiatry, nearly half of the people who died by suicide had visited their primary care physicians within a month of their death. Most reported minor symptoms such as trouble sleeping or headaches.

Bridging the gap with integrated care

Unfortunately, this tendency to see the primary care doctor for mental health issues is quite dangerous. Most primary care physicians are not properly trained in identifying risk factors for suicide, which means they cannot protect those patients in the ways that are most needed. If those patients who went to their doctor for headaches or sleepless nights could then see a medical heath professional on the same day, they would have access to the standard of care they need to reduce the risk of dying by suicide. Because those services are rarely available in rural areas, thousands of people are put at elevated risk.

Experts cited in the Times article have suggested adding a mental health component to primary care practices, either by having an affiliated psychiatrist practicing in the same building or by using video conferencing to get patients immediately evaluated by an off-site psychiatrist. That way, patients can seek mental health services without having to go to a building specifically dedicated to mental health – and thus avoid the weight of the social stigma.

However, with limited space and resources available, adding these services in rural areas is a challenge. Additional resources are needed to provide those essential mental health services to those who are most in need of help. Just as importantly, the public needs to be educated about the high cost of letting mental health services suffer – and the social stigma needs to be replaced with an understanding that seeking treatment for mental health is no different from seeking treatment for any other medical issue.

If you or a loved one has been effected by a death by suicide, contact Skip Simpson today. He knows that a person who is at high risk of suicide cannot seek help that isn’t there. Contact him today for a free and confidential case evaluation.

If you are a mental health provider, you absolutely must read “Constant Observation of Suicidal Patients: The Intervention We Love to Hate,” by Mark J. Russ, MD (Journal of Psychiatric Practice, 2016;22;382–388). This study is a must-read for psychiatric and general hospital risk managers, staff, and attending psychiatrists – because it provides valuable information that can help you protect your patients from serious harm or death.

Constant observation (CO) is defined by Dr. Russ as maintaining uninterrupted, physically close visual surveillance of a patient. He says it has been a mainstay of the inpatient care of the acutely suicidal patient. But sadly, in many hospitals, rehabilitation centers and other residential facilities, patients at acute risk for suicide are not put under CO. This is a dangerous decision.

Though CO is the standard of care for these patients, some argue against its effectiveness. One argument against it is a lack of evidence to support its use. This is a tired excuse. Another is that CO is too expensive and time-consuming, as it requires a staff member to be with one patient at all times. This excuse, at its core, puts profits over patient safety.

Even with a clinician, nurse or other health-care professional allegedly near the patient, there have been a few reported deaths by suicide that have occurred while the patient was under CO. None however, explain how the attempt was made.

Attorney Skip Simpson has a case in which a patient was able to tie a sheet to a vent and hang herself while she was allegedly being constantly watched. The reason for this death was an unsafe environment of care, poor staff training and supervision, and lack of leadership in the hospital. These are all common root causes of suicide listed by the Joint Commission.

It costs money to have a safe place to keep suicidal patients, train and supervise staff and have solid leadership. It always comes back to money—money that bean counters don’t want to spend to protect patients. Skip Simpson will not give hospitals and incompetent leaders a pass, nor will juries.

Most, if not all of the cases of suicide by patients supposedly under CO involved clinicians and staff who did not uphold the strictest level of constant observation. Any time there is a shift change or other circumstance in which a patient is left unobserved, even briefly, there is the risk of a suicide attempt.

Patients deserve the highest level of care

Given the state of our knowledge for the past 20 years, at least, an argument against the effectiveness of CO cannot be made, according to Dr. Russ. Skip Simpson agrees. The axiom asserting that “the absence of evidence is not evidence of absence” applies in this circumstance. There may be weak reasons not to recommend CO as a strategy to mitigate suicide risk in the hospital, but lack of effectiveness cannot be one. The very fact that it would be unethical to test the question with a randomized controlled trial—where some patients are properly protected and others are not—speaks to the validity of its effectiveness.

Many experts agree that CO, like most other procedures, is most effective when all medical professionals are adhering to all safety protocols. The risk of suicide can be prevented by ensuring that all staff are properly trained and follow the proper care procedures. This process also relies heavily on communication between health professionals.

Another method of care for patients who are at risk of suicide is routine 15-minute checks, or Q15. However, this has proven to be ineffective and is dangerous. With this method of observation, patients at high risk of suicide are left alone for 15 minutes at a time. This puts highly vulnerable patients at even greater risk of a successful suicide attempt. Hundreds of patients die by suicide every year while being watched every 15 minutes.

In this respect, the healthcare field is lagging behind virtually every other field. For instance, the reason most new bridges are now safe – ironically – is that so many collapsed in the early days. Whenever a bridge collapsed anywhere, bridge engineers flocked to the site to learn why. Once they found out, they made sure no one ever allowed that problem to arise again. They followed the “stop-it-next-time” rule. In contrast, hospitals do a root cause analysis of their suicides and bury the results. The public, other hospitals, researchers, the CDC, and even the hospital’s own staff don’t know why the suicide on a Q15 occurred.

Predicting a person’s exact moment of suicide is difficult; this is a reason at-risk patients are hospitalized. Every 15-minute watch for acutely suicidal patients must be eliminated. Medical professionals must be properly trained in using appropriate safety protocols, including CO. Overall, there needs to be improvement in the quality of care to help reduce the risk of suicide. This is easy—it means that the priority in healthcare must be the patient, not the pocketbooks of healthcare executives.

If you have lost a loved one to suicide while they were in an inpatient program, hospital or residential facility, contact Skip Simpson today. He has the unique expertise to help you get through this difficult time.

The suicide rate in the United States has reached its highest level since 1986 for nearly every age group in the country, according to statistics compiled recently by the National Center for Health Statistics.

The study examined the suicide rate for all age groups between 1999 and 2014, according to The New York Times. Nationwide, the suicide rate increased by 24 percent during this 15-year period. The study also compared the overall suicide rate nationwide dating even further back. In 2014, a total of 42,774 died from suicide or 13 per 10,000 people, the highest overall rate since 1986.

Some of the biggest increases in the suicide rate occurred among men and women 45 to 64 years old. The rate among women this age increased 63 percent between 1999 and 2014. Among men this age, the suicide rate rose 43 percent during the same time period.

Why did the suicide rate increase nationwide?

There are many reasons why experts believe more people are dying by suicide in the United States. One reason cited in The New York Times article concerns a possible link between suicide in middle-aged adults and concerns about work and personal finances. The Times cited a study conducted by Katherine Hempstead of the Robert Wood Johnson Foundation.

Other experts studying the issue believe that income inequality may be a factor. “This is part of the larger emerging pattern of evidence of the links between poverty, hopelessness and health,” said Robert D. Putnam, a professor of public policy at Harvard University, interviewed by The New York Times.

Those comments were echoed by Dr. Alex Crosby, an epidemiologist at the Centers for Disease Control and Prevention, who studied the association between the nation’s economy and its suicide rate dating back to the 1920s. “There was a consistent pattern,” Crosby said in an interview with The New York Times. “When the economy got worse, suicides went up, and when it got better, they went down.”

Other reasons why more people are dying by suicide

However, the statistics compiled by the National Center for Health Statistics did not include data about the income of the people who died by suicide. In addition, the theories linking suicide with economic downtowns cannot explain recent economic trends. Since 2010, the unemployment rate has steadily declined each year. As a result, some experts analyzing the issue have questioned whether a link exists between the economy and the nation’s suicide rate.

Instead, others have cited inadequate health care and failure to diagnose depression among adults as a possible explanation for suicides. Some mental health care professionals do not take patients’ warning signs of depression and suicide seriously, according to attorney Skip Simpson, who regularly works with families nationwide on negligence and medical malpractice cases involving suicide. As a result, people dealing with thoughts about suicide sometimes do not receive the necessary treatment they need to address such issues.

Suicide is the second leading cause of death among young people between the ages of 15 to 24 in the United States. According to the American Association of Suicidology, more than 5,000 young adults and teenagers in this age range die by suicide each year. Unfortunately, teen depression is not understood as well as it should be and treatment methods – including inpatient treatment – are not always effective at providing young people with the services and support that’s necessary.

When a teen receives inpatient or outpatient care and still takes his or her own life, it is important to determine if the mental health counselors or care providers lived up to their duties as required by law. A failure to provide appropriate care and to perform a proper suicide assessment can result in a claim against any care provider, while inpatient facilities can also be held accountable for failure to adequately  monitor patients to prevent death by suicide.

Inpatient and Outpatient Treatment Must Help Teens Fight Suicidal Ideation

Argus Leader recently took an in-depth look at the problem of teen suicide, sharing the story of a 17-year-old who took her own life after a lengthy battle with depression. The young woman was a volunteer and mentor to others who took dual credit classes and who planned to attend university in the fall. Unfortunately, her family had a history of mental illness and the young woman began to develop depression after a move and after her parent’s divorce when she was in the fifth grade. She was also a victim of bullying in school, and she began cutting which is a common coping measure for teens who struggle to deal with emotional pressure. She also attempted suicide in fifth grade, and was hospitalized in an inpatient treatment facility.

She ultimately would make several more suicide attempts and be hospitalized at the same inpatient facility several times before dying by suicide.  She received a variety of different treatments, including transcranial magnetic stimulation, which is a relatively new depression treatment aimed at stimulating nerve cells in the brain using magnets. Unfortunately, the treatment efforts were not successful and she died by suicide this year.

Her story is similar to the struggles endured by many other teens, who care providers often do not understand how to treat effectively. Efforts are underway to improve the care young people receive, and 20 states have now adopted the Jason Flatt Act to require public school personnel to complete required training on youth suicide prevention and awareness.

Awareness is important, but can only go so far if the teens who are identified as being at risk are not provided with treatments that make a difference in their depression. Unfortunately, if mental health care providers and inpatient treatment centers do not develop more effective ways of treating and preventing teen suicide, tragic deaths of young people will  continue to occur.

Identifying people at risk of suicide is an essential step to providing these patients with the care they require.  A new study shows care providers in the emergency room have an important role to play in identifying people at risk; this is yet another study stating the obvious.  Healthcare professions in an ER setting must do their part to ensure patients are identified so they can receive appropriate care. If not, an attempted suicide may occur within minutes to hours of an unthoughtful disposition.

ER Nurses Can Help Identify Patients at Risk of Death by Suicide

NewsWise reported on the recent study showing the important role emergency room caregivers can play in preventing a suicide. The research was conducted by UMass Medical School.  Researchers discovered when emergency room nurses conducted a universal suicide risk screening, almost double the number of at-risk patients were identified. At-risk patients included those who were positively identified as thinking about suicide or patients with attempted suicide.

The study spanned a five year period. During this time, there were 236,791 visits to emergency rooms included in the study. Suicide risks screenings performed on patients increased from 26 percent to 84 percent of patients undergoing screening over the study period. This increased the rate of detection of suicide risk from 2.9 percent to 5.7 percent.

The suicide screening performed in the emergency room was simple. Nurses in the ER departments were trained to administer a brief questionnaire to patients focused on three risk factors for suicide: depressive symptoms, lifetime attempts to die by suicide, and active suicidal ideation.

Patients were identified as having a positive screen if they had either confirmed they have active suicidal ideation or if they had attempted to die by suicide within six months of the time of the visit to the emergency department.  With this screening process, a subset of patients was identified whose risk of suicide was serious enough the patients needed inpatient psychiatric treatment. Other patients were identified who needed additional evaluation and intervention resources such as a self-help safety card and information about a suicide prevention lifeline.

The lead author of the study indicated: “Our study is the first to demonstrate that near-universal suicide risk screening can be done in a busy ED during routine care. The public health impact could be tremendous, because identification of risk is the first and necessary step for preventing suicide.”  The lead author is correct and we applaud the entire team performing the research.  We hope that the study is transformed into action in the emergency departments and the study is not just a group soliloquy among academics.

No further efforts to help identify risk of suicide in emergency departments are needed at this time.  This need has been answered by the Suicide Prevention Resource Center last year, 2015.  Skip Simpson highly recommends the outstanding work produced by the SPRC: “Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments.”  This important work (the ED Guide) is designed to assist emergency department (ED) providers with decisions about the care and discharge of patients with suicide risk.

When patients seek either inpatient care or outpatient treatment for mental illnesses including depression, the treatment they receive is often inadequate. Depression is one of the greatest risk factors for suicide, especially among severely depressed patients who are hospitalized due to suicidal ideation. Unfortunately, even in inpatient settings where patients are supposed to receive treatment from consummate professionals, mental healthcare providers are often left guessing, because of poor training, on what treatments will be effective with no actual scientific method of helping patients.

Scientific America calls the current approach to treating mental illnesses, including depression, the “shotgun approach,” and describes the shortcomings of this treatment method. The term refers to the fact psychiatrists often try many different types of medications in a very imprecise manner.

When patients receive inpatient treatment or outpatient treatment and the wrong medications are provided to treat depression, some of these medications can actually increase the risk of suicide- especially if patients end up having to stop taking the drugs and going through a withdrawal process. Mental health professionals may sometimes be held accountable for the harm their failed treatment efforts can cause, including when a patient attempts to die by suicide. This is especially true in an inpatient setting where care providers should quickly be able to identify when a medication is doing more harm than good.

Improving Mental Healthcare in Inpatient and Outpatient Settings To Prevent Death by Suicide

Centers for Disease Control and Prevention list a history of mental disorders, and particularly clinical depression, as among the top risk factors for suicide. Unfortunately, while there are many medications to treat mental disorders, a trial-and-error approach is usually taken to decide which of these different drugs to try.

Scientific America gives an example of one patient who had been in and out of intensive psychiatric care over close to two decades. She had been diagnosed with bipolar disorder and had experienced periods of suicidal depression.  She had been prescribed antipsychotics, antidepressants, anticonvulsants, mood stabilizers, and anticonvulsants. She had also undergone group and individual therapy, cognitive therapy, and behavioral therapy- but none of the treatments received had made any lasting impact.  The medication she’d been prescribed did lots of different things, from blocking dopamine to focusing on norepinephrine.

Her story was common, as mental illnesses are frequently treated based on guessing which medications will affect observable symptoms, rather than based on getting a correct diagnosis of an underlying cause and treating that specific condition. Genetics and brain imaging in the future could provide clearer answers regarding what is actually going wrong in the brain structure or brain function so more accurate treatments could be provided, and there has been extensive research in this area. Unfortunately, there are continued challenges in finding common markers within different diagnoses.

While treating with medication and experimenting with different drug therapies is challenging and imprecise, it is likely to be the most common method of providing care until research advances. When a patient is in an inpatient setting and different medications are being experimented with, it is imperative for care providers to ensure they are monitoring the effects of medication and are alert for any potential risk of suicidal ideation.  When nothing is working,  Electroconvulsive therapy (ECT) should quickly be considered and carefully explained to the patient and the patient’s family.

Montana universities are taking steps to address suicide epidemic

At the first ever Montana Suicide Prevention Summit last month, advocates for suicide prevention called for mental health and emotional education for the general public, starting at the grade school level.

Marny Lombard, the mother of a Montana State University student who died by suicide in 2013, and Karl Rosston, the suicide prevention coordinator for Montana’s Department of Health and Human Services, were among the key speakers at the summit. Both emphasized the need to prepare ordinary people to recognize and appropriately address suicide risk factors rather than relying exclusively on mental health professionals.

Montana has the nation’s highest suicide rate, nearly double the national average. Every other state in the Rocky Mountain region is close to the top as well. And while some suicide risk factors, such as altitude, are geographically fairly unique to the Rockies, most hold significance nationwide.

Rosston cited several suicide risk factors common in Montana and the surrounding states, including social isolation, easy access to firearms, high rates of alcohol consumption and a social stigma against mental illness. Many people in the West, particularly men, are uncomfortable seeking professional help for depression or emotional health – and that’s true in other parts of the country as well.

That means friends and family must play a key role in encouraging, supporting and protecting people at risk of suicide. Lombard pointed out that at-risk college students are much more likely to turn to their friends than professors or mental health professionals.

Friends and family members can help to prevent inpatient suicide

Even in cases where at-risk persons are already receiving professional help, friends and family play a hugely important role in preventing suicide. The unfortunate reality is that many mental health professionals lack the training and experience to recognize and appropriately address the warning signs that a person is at risk of death by suicide.

Friends and family members who know a person’s interests, background and personality are especially well-equipped to recognize early signs that a person may be at risk. Even when mental health professionals have the necessary training – and, again, many do not – there is no substitute for actually knowing the person.

Relatives and close friends of people in inpatient care need to be their advocates and their support system. Frequent visits and phone calls not only reduce the feeling of isolation that leads to many suicides, but also provide opportunities for loved ones to recognize those warning signs and work with caregivers to appropriately intervene.

Unfortunately, many mental health professionals fail to take appropriate steps to help patients at risk of suicide, even when they are warned of the danger. When that happens, friends and family members with some training in mental health are well-equipped to hold negligent caregivers accountable.

Skip Simpson has a couple of recommendations to understand what a friend or loved one can do to better understand how to help.  First, obtain training from the QPR Institute. There are three steps anyone can learn to help prevent suicide: Question, Persuade, and Refer.  See https://www.qprinstitute.com

Also, there is a quick read called “The Suicide Lawyers: Exposing Lethal Secrets” wherein Skip Simpson and his then partner were interviewed about what Skip Simpson had learned in his years of litigating suicide cases. Skip heard many clients say after starting litigation “if I had only known.” Skip Simpson wanted everyone to know what to look for and what to do before tragedy hit a friend, loved one, business colleague or anyone.

Zero Suicide represents a commitment to identify, protect, and treat people who are at risk of suicide. Central to this commitment is the ability to record and properly share accurate information about a patient’s history and treatment. Without this information, each clinician that treats a patient must start from scratch — an inefficiency that will frustrate health care providers and patients, as well as affect the quality of care. Careful documentation also allows us to understand how health care systems can be improved and patient care made more effective.

The documentation essential to Zero Suicide has another benefit. It can protect clinicians and institutions from malpractice suits. Suicide is the most common cause of legal action against mental health care professionals. The central issues in most suicide malpractice cases are whether the clinician should have anticipated the risk of suicide and whether he or she provided care appropriate to this risk. Showing that a clinician met the standard of care appropriate for suicide risk can stop a malpractice suit in its tracks. Patient care should be documented in real time. Juries may suspect that medical records created after the fact rather than during treatment are inaccurate or self-serving.

Assessments of suicide risk should be carefully documented. It is a fundamental principle of good practice that risk assessment is more than simply using a screening instrument—clinical observation and judgment are also essential. These observations should be documented in the patient’s medical record. Patient responses to questions about suicide and self-harm should be recorded in their own words, and quotation marks used to clearly distinguish which statements represent clinical judgments and which are verbatim reports of what a patient said.

Embarrassment and anxiety can make patients reluctant to admit they are thinking about suicide. They may want to protect family secrets about substance abuse, mental health disorders, sexual abuse, or family violence. They may be in denial or afraid of being institutionalized or feel that no one can help. Involving family members can be crucial to accurately assessing a patient’s risk and making care decisions. Family members can provide information that the patient can’t—or won’t—and this information should be carefully recorded. It should also be noted if family members cannot be reached or are uncooperative. If a suicide results in a malpractice suit, it is the family that will sue. Accurate information about the family’s involvement—or lack of involvement—in patient care can be critical to the outcome.

The clinician should also document the decisions made while developing a patient care plan, how this care plan was implemented, and the criteria used to decide the steps needed to preserve the patient’s safety (such as whether the patient admitted to actively planning his or her suicide and whether the patient has access to firearms).

It is also important for the clinician to document his or her review of medical records and consultations with other service providers. If medical records or prior providers are not available, all attempts to obtain records and reach providers should be documented.

Focusing on the possibility of malpractice lawsuits turns the clinician’s attention away from the patient to him- or herself. Thoroughly and accurately documenting the assessment and care of patients who may be at risk of suicide will help deter malpractice lawsuits as well as contribute to quality care, patient safety, and the ability of clinicians and the health care system to work toward the goal of zero suicides.

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