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Ligature and/or Suicide Risk Reduction - Use of an Evidence-based Process to Assess Risk

NPSG.15.01.01 EP 3 requires use of an evidence-based process to conduct a suicide risk assessment on patients who have screened positive for suicide ideation and those that have expressed suicide ideation during care. What does this mean? (Effective: July 1, 2019)

Any examples are for illustrative purposes only.

Patients with suicidal ideation vary widely in their risk for a suicide attempt depending upon whether they have a plan, intent, history of attempts, etc. It is important to conduct an in-depth assessment of patients who screen positive for suicide risk to determine how to appropriately treat them.

The use of an evidence-based assessment tool, in conjunction with clinical evaluation, is an evidenced-based process effective in determining overall risk for suicide. The use of validated tools is strongly encouraged, and it is acceptable for organizations to use language that is more appropriate for their patient population, if the questions adhere to the intent of the original validated tool.

If the organization does not use an evidenced-based tool, the following conditions must be met:  
  • Organization can demonstrate what evidenced based resource(s) their assessment is based off
  • The assessment asks directly about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors
  • How level of risk was determined is clearly documented
The evidence-based process must determine a level of suicide risk (e.g. high, moderate, or low). This overall level of risk must be clearly documented, with clinical justification, as well as the plans to mitigate the risk for suicide.

Additional Resources
Suicide Prevention Portal
Manual: Hospital and Hospital Clinics
Chapter: National Patient Safety Goals NPSG
Last reviewed by Standards Interpretation: February 01, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: May 07, 2019 This Standards FAQ was first published on this date.
This page was last updated on February 01, 2022 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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