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Sunday 2:56 CST, February 14, 2016

Standards FAQ Details


National Patient Safety Goals (NPSG) (Hospital and Hospital Clinics / Hospitals)

Suicide Risk Reduction - NPSG - Goal 15 - 15.01.01
Revised | December 09, 2008

Applicability to general hospitals

Q. In our hospital, we do not have a psychiatric unit but we do admit patients that have psychiatric disorders along with their medical conditions. Does this requirement apply to us?

A. NPSG.15.01.01 applies to all patients in organizations surveyed under the BHC (behavioral) standards, all patients in psychiatric hospitals, and to any patient in a general hospital with a primary diagnosis or primary complaint of an emotional or behavioral disorder. At this time, suicide risk assessment of patients with secondary diagnoses or secondary complaints of emotional or behavioral disorders is encouraged but not required.

For purposes of this requirement, the phrase “emotional or behavioral disorders” refers to any DSM diagnosis or condition, including those related to substance abuse.

The phrase “being treated” is interpreted in terms of the patient’s diagnosis or presenting “complaint.” The nature of the treatment is really not the issue.


Q. With respect to general hospitals, is this just an inpatient requirement?

A. No. NPSG.15.01.01 applies to all hospital services, that is, it applies to any facility, location, or practice setting that is included in a survey conducted under these standards, but only with respect to patients as defined above. So, an emergency department or hospital-based ambulatory care facility or even hospital-based office practices, if they are part of the hospital survey, will be within the scope of this requirement.

Emergency departments

Q. What is the expectation for a patient brought to our general hospital ED for a psychiatric-related condition when the patient will most likely be transferred to a psychiatric facility?

A. The requirement under this safety goal is that a suicide risk assessment will be done in the receiving ED and appropriate precautions will be taken. There are several cases in The Joint Commission’s sentinel event database of suicides in emergency departments while the patients were awaiting transfer.

Applicability-sample scenarios

Q. For each of the following general hospital scenarios, would a suicide risk assessment be required?

  1. A patient seen in the ED for a fracture sustained in the act of attempting suicide
    • This patient has already identified him/herself as “at risk” by virtue of the suicide attempt. A risk assessment is not necessary. Treatment of the fracture and the emotional condition is needed. As the patient recovers, an assessment of the degree of ongoing risk for suicide is required in order to plan the appropriate continuing care.
  2. A patient admitted to the ICU for detoxification
    • Detoxification is a medical treatment. At the time of admission to the ICU, the primary diagnosis is medical. However, as the patient recovers, the primary diagnosis will shift to the underlying psychiatric or substance abuse problem. When the patient is able a suicide risk assessment will be required.
  3. A patient admitted to OB in active labor, has history of severe post-partum depression after a previous childbirth
    • The decision to do a suicide risk assessment and when to do it would be left to the responsible practitioner. It would not be required under goal 15A, however, this type of patient represents a high risk.

Screening vs. comprehensive assessment

Q. For psychiatric hospitals and residential treatment facilities, are we required to screen all individuals admitted and to conduct a more detailed risk assessment, as appropriate, or to conduct a thorough suicide risk assessment for every individual who presents for admission?

A. The details of the risk assessment process, when required, are left to the individual organization to decide. A two-stage process—for example, screening followed by a comprehensive assessment, as appropriate—is acceptable.

Crisis hotline

Q. NPSG.15.01.01 EP 3 says, “The hospital provides information such as a crisis hotline to individuals at risk for suicide and their family members..” Does this mean we have to provide our own crisis hotline?

A. No. Actually, it means that organizations must provide information about the availability of a crisis hotline (not necessarily its own) or other resources, and how to access them if needed. This would be required for any patients identified as “at risk” based on the assessment process as you have conducted it.