Title: Preventing Inmate Suicide: The Ultimate Patient Safety Measure
Headings: Preventing Inmate Suicide: The Ultimate Patient Safety Measure
Preventing Inmate Suicide: The Ultimate Patient Safety Measure
Start with Screening
Screening is Only the Beginning
Making the Most of a Bad Outcome

Content: First, every completed suicide, as well as serious suicide attempt (i.e., requiring medical treatment and/or hospitalization outside the facility), should be examined through a multidisciplinary morbidity-mortality review process that includes representation from correctional, mental health, and medical divisions. Exclusion of one or more disciplines will severely jeopardize the integrity of the review. Second, the primary purpose of the review is two-fold: “ What happened in the case under review?” and “What can be learned to reduce the likelihood of future incidents?” Third, the review, separate and apart from other formal investigations that may be required to determine the cause of death, should include a critical inquiry of: The circumstances surrounding the incident
Facility procedures relevant to the incident
All relevant training received by involved staff
Pertinent medical and mental health services/reports involving the decedent
Possible precipitating factors (i.e., circumstances which may have caused the suicide or serious suicide attempt)
Recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures
Suicide is a potential patient safety issue throughout the incarceration period. By being ever mindful of this possibility, we may have opportunity to prevent patient self-injury and death. Organizational culture and systems can support these efforts. How do you prevent suicide in your setting?