Ligatures and/or Suicide Risk Reduction - Screening Requirements (HAP/CAH)

Is suicide risk screening required for all patients?

Any examples are for illustrative purposes only.

No, the National Patient Safety Goal does not require organizations to universally screen all patients for suicidal ideation. Screening patients for suicide risk with secondary diagnoses or secondary complaints of emotional or behavioral disorders is encouraged but not required.

It is important for clinicians to be aware that patients being treated primarily for a medical condition may also have  behavioral tendencies that, if triggered, may lead to self-harm.  For example, changes in health status  resulting in a poor prognosis, chronic pain resulting from injury or illness, etc.

Psychosocial changes, such as sudden loss of a loved one, broken relationships, financial hardship, etc., can also trigger self-harm behaviors. These patients may also be at risk for suicide,  therefore, it is important for clinicians to properly assess these individuals for suicidal ideation as part of their overall clinical evaluation, when indicated.

Roaten K, et al. Development and Implementation of a Universal Suicide Risk Screening Program in a Safety-Net Hospital System. Joint Commission Journal of Quality and Patient Safety, 2018 Jan;44(1):4-11.
Last updated on March 19, 2020
Manual: Hospital and Hospital Clinics
Chapter: National Patient Safety Goals NPSG

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