Ligatures and/or Suicide Risk Reduction - Emergency Department - Ligature Risks That Cannot Be Removed

What if all objects posing a ligature risk cannot be removed from the area where high-risk patients are being treated or triaged ?

Any examples are for illustrative purposes only.

Please refer to the Emergency Department FAQs titled "Does every emergency department need to have a “safe room”? and "Do we have to assess every patient for suicide risk who comes into the emergency department ?". The organization should remove all items that can be removed from the room and provide an appropriate level of monitoring based upon patient’s suicide risk and the ligature/self-harm items that remain in the environment to ensure patient care is provided in a safe environment. The organization is expected to develop and implement a policy/procedure to direct staff, provide education to staff as to the procedure, and ensure demonstrated competence and compliance. If the organization has a designated “safe room,” The Joint Commission expects this room to be ligature resistant.

This FAQ was also published in the Perspectives® Newsletter, July 2018, Volume 38, Issue 7 - The Official Newsletter of The Joint Commission.
Last updated on March 19, 2020
Manual: Hospital and Hospital Clinics
Chapter: National Patient Safety Goals NPSG

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