Ligatures and/or Suicide Risk Reduction - Applicability in a Hospital Setting

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

Any examples are for illustrative purposes only.

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, regardless of registration status (IP, OP, ED, Obs, etc).  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 Diagnostic Statistical Manual (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.  Additional information regarding assessing suicide risk has been published in our Sentinel Event Alerts:
Last updated on March 19, 2020
Manual: Critical Access Hospital
Chapter: National Patient Safety Goals NPSG

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