Ligatures and/or Suicide Risk Reduction - Environmental Risk Assessment Expectations in Non-psychiatric Units/Areas in General Hospitals

What are The Joint Commission’s expectations for an environmental risk assessment in non-psychiatric units/areas in general hospitals where patients at risk for suicide are housed (for example, non-designated patient rooms within medical/surgical units, emergency departments)?

Any examples are for illustrative purposes only.

The Joint Commission requires:
1. Thoughtful evaluation of the environment,
2. A plan, and 
3. Available resources to guide staff when housing patients at risk for suicide in a patient room in a non-designated space.  

The evaluation is meant to be a proactive process to, at a minimum, identify self-harm issues prior to the patient being placed in the room.  
The plan needs to address who is responsible to remove any objects identified to be of a self-harm nature and resources to guide staff, which may include but are not limited to:
• Checklists identifying the self-harm objects to be removed
• Electronic flags (e.g. the patient you are placing in a medical/surgical room is high risk and you should sweep the room for items not essential for patient care which may pose a self-harm risk)
• Competency/training for all sitters who will be with high risk patients to do the environmental assessments
• Visual reminders (e.g., posters) of the most common items that are significant risks on the unit
• On-site psychiatric professional who is available to complete an environmental risk assessment in areas where staff do not have the training to do this independently

Last updated on March 19, 2020
Manual: Hospital and Hospital Clinics
Chapter: National Patient Safety Goals NPSG

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