Ligature and/or Suicide Risk Reduction - NPSG.15.01.01 - Applicability in Non-Psychiatric Settings

In our hospital, we do not have a psychiatric unit, however, we do admit patients that have psychiatric disorders and/or behavioral conditions 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 Behavioral Healthcare and Human Services standards (CAMBHC), all patients in psychiatric hospitals, any patient in a general hospital who is being treated or evaluated for a behavioral condition as their primary reason for care, and all patients who express suicidal ideation during the course of care regardless of their 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 and/or conditions that are NOT part of the current assessment or treatment is encouraged but not required. For purposes of this requirement, the phrase “behavioral conditions” refers to any Diagnostic Statistical Manual (DSM) diagnosis or condition/symptomology, including those related to substance abuse. The phrase "being treated" is interpreted in terms of the patient's diagnosis or presenting complaint, condition, and/or symptomology. If a patient is being evaluated or treated for a behavioral compliant, condition, or symptomology, the standard applies whether a formal psychiatric diagnosis is present or not.

For additional information regarding environmental requirements in non-psychiatric settings review the following FAQ: Environmental Risk Assessment Expectations in Non-psychiatric Units/Areas in General Hospitals

Additional Resource:
Suicide Prevention Portal


Last updated on February 22, 2021
Manual: Critical Access Hospital
Chapter: National Patient Safety Goals NPSG

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