to main content Ligature and/or Suicide Risk Reduction - NPSG.15.01.01 - Applicability in Non-Psychiatric Settings | Hospital and Hospital Clinics | National Patient Safety Goals NPSG | The Joint Commission
Ligature and/or Suicide Risk Reduction - NPSG.15.01.01 - Applicability in Non-Psychiatric Settings

Our hospital does 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


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: April 11, 2016 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.

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form