title: Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration.
abstract: BACKGROUND
  Veterans possess many risk factors for suicide, making suicide prevention in the Veterans Health Administration (VHA) a particular challenge.
  
  
  METHODS
  An analysis was conducted of 94 aggregated root cause analyses (RCAs) for parasuicidal behavior and 43 single-case suicide RCAs submitted from 75 VHA facilities to determine primary root causes for suicide and parasuicidal behaviors and to gain information about action plans, success factors and obstacles to improvement. Telephone follow-up interviews were conducted with each facility.
  
  
  RESULTS
  The aggregate reviews included 775 individual cases of parasuicidal behavior. The top root causes of parasuicidal behavior were poor assessment and communication of patient risk, patient stressors, and need for staff and patients training. Forty-eight percent of the action plans developed to address the root causes involved a policy change, 30% involved staff training, and 14% involved making a specific clinical change. Eight-eight percent of the actions adequately addressed the root cause, of which 68.1% were fully implemented.
  
  
  CONCLUSIONS
  There is little agreement on the definition of "parasuicide," and it is likely the case that parasuicide behaviors are underreported in our system. To encourage reporting, patient safety staff should collaborate with providers and use a more inclusive definition of parasuicide.
authors.affiliation: Field Office, VA National Center for Patient Safety, White River Junction, Vermont, USA. Peter.Mills@va.gov
authors.forename: Peter D
authors.initials: PD
authors.lastname: Mills
authors.forename: Julia
authors.initials: J
authors.lastname: Neily
authors.forename: Diana
authors.initials: D
authors.lastname: Luan
authors.forename: Andrea
authors.initials: A
authors.lastname: Osborne
authors.forename: Kierston
authors.initials: K
authors.lastname: Howard
mesh_terms: D006787:Hospitals, Veterans; D006801:Humans; D007407:Interviews as Topic; D017751:Safety Management / Q000379:methods* / Q000458:organization & administration; D016728:Self-Injurious Behavior / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control*; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D000092864:Suicide Prevention