title: Learning from prevented suicide in psychiatric inpatient care: an analysis of data from the National Patient Safety Agency.
abstract: BACKGROUND
  Inpatient suicide is a tragedy, and removal of the means is only a partially effective strategy.
  
  
  OBJECTIVE
  To identify the mechanisms by which attempted inpatient suicides are prevented, so that their use can become more widespread.
  
  
  METHODS
  Analysis of one year of nationally reported suicide attempts on inpatient psychiatric wards from the National Patient Safety Agency.
  
  
  RESULTS
  Patients are discovered in the act by staff checks (medication rounds, meals, routine activities, and intermittent observation) and by staff being caringly vigilant and inquisitive (noticing the absence of patients, their psychological distress, physical state, responding to unusual noises, etc.).
  
  
  CONCLUSIONS
  The use of intermittent observation and other patient checks should be increased, and particularly directed to private areas of the ward. All staff should act on any sense of unease or feeling that something about a patient, their behaviour, or noises on the ward, are not right.
authors.affiliation: Institute of Psychiatry, London, United Kingdom. len.bowers@kcl.ac.uk
authors.forename: Len
authors.initials: L
authors.lastname: Bowers
authors.forename: Charlotte
authors.initials: C
authors.lastname: Dack
authors.forename: Noreen
authors.initials: N
authors.lastname: Gul
authors.forename: Ben
authors.initials: B
authors.lastname: Thomas
authors.forename: Karen
authors.initials: K
authors.lastname: James
mesh_terms: D005260:Female; D006801:Humans; D007297:Inpatients; D008297:Male; D008605:Mental Health Services / Q000458:organization & administration*; D012449:Safety; D014481:United States; D000092864:Suicide Prevention