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Ligature and/or Suicide Risk Reduction – Suicide Risk Reassessment

What is required for suicide risk reassessments?

Any examples are for  illustrative purposes only.

Organizations are required to develop and follow written policies and procedures addressing the care of patients identified as at risk for suicide, including guidelines for suicide risk reassessment. Reassessment guidelines should address how often reassessments will occur as well as additional criteria that would trigger a reassessment, for example, a change in patient status, endorsement of suicidal ideation, and/or suicidal or self-harm behaviors or gestures.  An evidence-based process must be used to conduct suicide risk reassessments for individuals who have screened positive for suicidal ideation and were further assessed for suicide risk. At minimum, reassessments must directly ask about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.   

The use of an evidence-based assessment tool, in conjunction with clinical evaluation, is an evidenced-based process effective in determining overall risk for suicide. The use of evidence-based tools is strongly encouraged, and it is acceptable for organizations to use language that is more appropriate for their patient population. 

If the organization does not use an evidence-based tool, the following conditions must be met:
  • Organization can demonstrate what evidenced based resource(s) their reassessment is based off
  • The reassessment asks directly about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors
  • How level of risk was determined is clearly documented
The evidence-based process must determine a level of suicide risk (e.g. high, moderate, or low). This overall level of risk must be clearly documented, with clinical justification, as well as the plans to mitigate the risk for suicide.

Additional Resources
Suicide Risk Reduction Resources
 
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: February 02, 2021 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.
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