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.

Additional Resource
Suicide Prevention Portal
Last updated on February 19, 2021
Manual: Hospital and Hospital Clinics
Chapter: National Patient Safety Goals NPSG

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