Failure of our major training and treatment institutions for Suicide Prevention

Paul Quinnett, Ph.D. Clinical Assistant Professor

Skip Simpson

As co-authors of this input, Skip Simpson and I and have worked together many years in the common cause of preventing suicide, especially among consumers of mental health services. Skip is an attorney who specializes in suicide malpractice, and I am clinical psychologist specialized in suicide prevention.

In full disclosure, the Alliance should know that we (the undersigned) are serving on a multidisciplinary writing committee of the American Association of Suicidology tasked with issuing a white paper related to NSSP recommended training goals and objectives as they relate to patient safety. The release of this paper is scheduled for the fall of 2011. Comments and observations stated in this letter will be fully resourced to published citations in published scientific literature and other documents.

The final title of this white paper is yet undecided and its contents cannot be disclosed at this time but its thrust and purpose is to bring public and professional attention to the abject failure of our major training and treatment institutions to address the clinical training goals and recommendations of the 2001 National Strategy for Suicide Prevention.

In a nutshell, patient safety is imperiled by a lack of training and demonstrated competence in the detection, assessment, management and inpatient monitoring of suicidal patients. This continuing ignorance contributes substantially to preventable patient morbidity and mortality.

The fundamental problem is that the vast majority of clinicians don't know what they don't know. For example, even the basic premise that any potentially suicidal patient should be considered 'high risk' and monitored continuously until evaluated by a trained, well-qualified clinician is neither widely understood nor codified in agency or hospital policy and procedures.

The result? Repeated systemic failures and avoidable catastrophic adverse events.

It is estimated that 1,500 patients die each year by suicide in our hospitals and many thousands more make non-fatal attempts. Among other factors, RCAs (root cause analyses) have shown these injuries and deaths can be attributed to inadequate staff training in a) how detect, assess, and communicate suicide risk, and b) how to properly monitor known at-risk patients in the ED or hospital.

Therefore, we recommend specific language changes in the CMS rules that requires organizations receiving federal funds to employ clinicians who can demonstrate training and competence in the care and management of suicidal patients in all inpatient, emergency room, residential, nursing home, or outpatient settings.

Even when clinicians know patients are at elevated risk for suicidal behaviors, antiquated, untested, and dangerous hospital practices persist; e.g., the so-called Q-15 monitoring level a routine intervention that allows patients 14 minutes and 59 seconds to kill themselves using obvious anchor points, ligatures and sharps.

This lack of core knowledge and skill competency in suicide screening and risk assessment is fixable at a cost of roughly eight hours of continuing education, or an equivalent amount of focused pre-licensure college, intern or residency training.

We remain unaware of any standard of care that allows healthcare professionals to needlessly endanger patients known to be at risk for suicidal behaviors when published studies point to improved practice models, use of environmental safety and procedural checklists, and evidence-based training in how to detect, assess, monitor and manage suicidal patients training that is now accessible, available, affordable, and adequate to improve the standard of care.

Further, for those agencies, hospitals and professionals receiving federal funds for mental health, substance abuse or emergency medical service, we recommend an actual individual demonstration of this core clinical competency for the following two reasons:

Yet in spite of repeated, research-driven recommendations by the Joint Commission, IOM, NSSP and others, many academics and institutional leaders in mental health have ignored repeated calls to remedy this training deficit.

We know, as the Action Alliance does, that the vast majority of training dollars spent by mental health organizations are to satisfy compliance requirements. We also know that training in suicide prevention can no longer be considered optional or elective.

Therefore, we recommend language changes in the pending CMS rules that requires organizations receiving federal funds to employ clinicians who can demonstrate training and competence in the care and management of suicidal patients in all inpatient, residential, nursing home, or outpatient settings.

To accomplish this goal, we have enclosed recommended language which we believe addresses this continuing unaddressed issue in patient safety. Thank you for your attention to this matter, and we look forward to any questions you might have.

Paul Quinnett, Ph.D.
Clinical Assistant Professor
University of Washington School of Medicine
President and CEO QPR Institute, Inc.

Skip Simpson, J.D.
Attorney at Law

  1. There is no ethical way to deny admission to, or otherwise limit, the practitioner's scope of practice by excluding suicidal patients
  2. Once a suicidal patient has been admitted/ accepted into treatment in any setting, that patient's personal safety is now an unavoidable professional duty. Failure to know how to detect, assess, manage, monitor and employ evidence-based interventions to mitigate suicide risk is simply not acceptable.
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