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Ligature and/or Suicide Risk Reduction - Monitoring Requirements

Does every patient being evaluated or treated for a behavioral condition require 1:1 monitoring? What is the monitoring requirement for patients at high risk for suicide?

Any examples are for illustrative purposes only.

No, not all patients being evaluated or treated for a behavioral condition require 1:1 monitoring. 

In units/areas that contain ligature and/or other safety risks, patients determined to be at high-risk for suicide must be under continuous observation with the ability to immediately intervene through the use of 1:1 observation - 1 qualified staff member to 1 high risk patient. A qualified staff member is one that has been trained and has demonstrated competence in working with suicidal patients and performing 1:1 observation. 

In inpatient psychiatric units/designated psychiatric areas that are ligature resistant and free from other safety risks, it is up to the organization to determine monitoring requirements for patients determined to be at high-risk for suicide and define such in their policy. 

Additional Resources 
Suicide Prevention Portal 
 
Manual: Critical Access Hospital
Chapter: National Patient Safety Goals NPSG
Last reviewed by Standards Interpretation: January 29, 2024 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: November 14, 2019 This Standards FAQ was first published on this date.
This page was last updated on January 29, 2024 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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