title: Safety strategies to prevent suicide in multiple health care environments.
abstract: BACKGROUND
  Patient suicide is one of the primary sentinel events reported throughout the United States. North Shore-Long Island Jewish Health System undertook a series of performance improvement efforts to identify suicide risk factors and develop a series of strategies and tools to maximize the safety of all vulnerable patients.
  
  
  METHODS
  A multidisciplinary task force conducted root cause analyses of 17 attempted and completed suicides and targeted inadequate patient assessment, poor communication, and knowledge deficits. A protocol was designed to ensure appropriate assessment, monitoring, and treatment of patients at risk for alcohol withdrawal and suicide. Poor communication as patients moved throughout the continuum of care was addressed through targeted education, a centralized intake model, and an inter-institutional transfer summary form. A continuous suicide risk assessment tool was incorporated into the inpatient behavioral health rounds.
  
  
  CONCLUSIONS
  The new tools have raised awareness, improved accountability, and encouraged best practices throughout the health system.
authors.affiliation: North Shore-Long Island Jewish Health System, Great Neck, New York, USA.
authors.forename: Yosef D
authors.initials: YD
authors.lastname: Dlugacz
authors.forename: Andrea
authors.initials: A
authors.lastname: Restifo
authors.forename: Kerri A
authors.initials: KA
authors.lastname: Scanlon
authors.forename: Karen
authors.initials: K
authors.lastname: Nelson
authors.forename: Anne Marie
authors.initials: AM
authors.lastname: Fried
authors.forename: Bruce
authors.initials: B
authors.lastname: Hirsch
authors.forename: Michael
authors.initials: M
authors.lastname: Delman
authors.forename: Richard D
authors.initials: RD
authors.lastname: Zenn
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Selzer
authors.forename: Alice
authors.initials: A
authors.lastname: Greenwood
mesh_terms: D000437:Alcoholism / Q000175:diagnosis; D002985:Clinical Protocols; D017831:Diagnosis, Dual (Psychiatry); D006778:Hospitals, Psychiatric / Q000592:standards*; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D009096:Multi-Institutional Systems / Q000592:standards; D009518:New York / Q000453:epidemiology; D017064:Process Assessment, Health Care; D011567:Psychiatric Department, Hospital / Q000592:standards*; D018570:Risk Assessment / Q000379:methods*; D012308:Risk Management / Q000379:methods*; D017751:Safety Management; D018571:Sentinel Surveillance; D012985:Software Design; D013405:Suicide / Q000706:statistics & numerical data; D013597:Systems Analysis; D000092864:Suicide Prevention