Ligature and/or Suicide Risk Reduction - Screening Requirements (HAP/CAH)
NPSG.15.01.01 EP 2 requires use of a validated screening tool for patients being evaluated or treated for behavioral health conditions as their primary reason for care. Is screening required for all patients and what is meant by a 'validated screening tool? (Effective: July 1, 2019)
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.
A validated screening tool is one that has been scientifically tested for reliability (the ability of the instrument to provide consistent results), validity (the degree to which the instrument is measuring the condition that it is designed to measure), sensitivity (the ability of the instrument to correctly identify individuals with the condition) and specificity (the ability of the instrument to correctly identify individuals without the condition).
Patients being evaluated or treated for behavioral health conditions often have suicidal ideation. Brief screening tools are an effective way to identify individuals who require further assessment to determine risk for suicide. Screening tools should be appropriate for the population to the extent possible (e.g., age-appropriate). When using validated screening tools, organizations should not change the wording of the questions because small changes can affect the accuracy of the tools.
In addition, it is important that organizations ensure that the chosen screening tool(s) are implemented and completed as directed by the creators of the tool(s). For example, the Columbia Suicide Severity Rating Scale (CSSRS) is a validated screening tool that contains six questions. Depending on the answer to the first two questions, additional questions apply. One or more questions may get missed if the tool is not implemented or completed as directed. Another example, the ASQ Suicide Risk Screen Tool, is a four-question validated screening tool, which also contains a fifth question to assess acuity. This question may get missed if the tool is not implemented or completed as directed. Therefore, if not completed as instructed, the validity of the tool to identify individuals who may be at risk for suicide is compromised. Ultimately, it is the responsibility of each organization to ensure that validated tool(s) are implemented and completed accurately.
Additional Resource
Suicide Prevention Portal
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.
A validated screening tool is one that has been scientifically tested for reliability (the ability of the instrument to provide consistent results), validity (the degree to which the instrument is measuring the condition that it is designed to measure), sensitivity (the ability of the instrument to correctly identify individuals with the condition) and specificity (the ability of the instrument to correctly identify individuals without the condition).
Patients being evaluated or treated for behavioral health conditions often have suicidal ideation. Brief screening tools are an effective way to identify individuals who require further assessment to determine risk for suicide. Screening tools should be appropriate for the population to the extent possible (e.g., age-appropriate). When using validated screening tools, organizations should not change the wording of the questions because small changes can affect the accuracy of the tools.
In addition, it is important that organizations ensure that the chosen screening tool(s) are implemented and completed as directed by the creators of the tool(s). For example, the Columbia Suicide Severity Rating Scale (CSSRS) is a validated screening tool that contains six questions. Depending on the answer to the first two questions, additional questions apply. One or more questions may get missed if the tool is not implemented or completed as directed. Another example, the ASQ Suicide Risk Screen Tool, is a four-question validated screening tool, which also contains a fifth question to assess acuity. This question may get missed if the tool is not implemented or completed as directed. Therefore, if not completed as instructed, the validity of the tool to identify individuals who may be at risk for suicide is compromised. Ultimately, it is the responsibility of each organization to ensure that validated tool(s) are implemented and completed accurately.
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: May 07, 2019
This Standards FAQ was first published on this date.
This page was last updated on March 24, 2023
with update notes of: Editorial changes only
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