Ligatures 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 assessment on patients who have screened positive for suicide ideation. 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, but 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 of
  • The assessment asks directly about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors
  • There is a clear synthesis documented as to how level of risk was determined
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.

Examples of evidence-based assessment tools include the Columbia-Suicide Severity Rating Scale (C-SSRS) Risk Assessment Version, Scale for Suicide Ideation - Worst (SSI-W) and Beck Scale for Suicide Ideation (BSI) 

Additional Resources:
Suicide Prevention Portal
Last updated on March 19, 2020
Manual: Critical Access Hospital
Chapter: National Patient Safety Goals NPSG

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