title: Case study illustrating risks of garrison unit watch for soldiers at risk of suicide.
abstract: Unit watch over suicidal patients by nonmedical soldiers is often necessary in a deployed environment, but this strategy's risks may outweigh its benefits in a garrison environment. This case study illustrates risks of unit watches that are difficult for medical personnel to effectively mitigate. The suicidal soldier in question was placed on a unit watch in lieu of psychiatric hospitalization, utilizing a plan agreed upon by all parties. However, within 2 days, the plan had degenerated to an unacceptable degree. A commander is always legally responsible for subordinate soldiers' conduct, but from a patient safety perspective, medical professionals must account for the inevitable periods of decreased oversight within a unit. Medical professionals who recommend a unit watch must consider the risks associated with this course of action, including instances such as the error chain detailed in this case.
authors.affiliation: 1st Stryker Brigade Combat Team, 25th Infantry Division, 1555 Gaffney Road, Room 234, Fort Wainwright, AK 99703.
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Brown
authors.affiliation: 1st Stryker Brigade Combat Team, 25th Infantry Division, 1555 Gaffney Road, Room 234, Fort Wainwright, AK 99703.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Sheridan
mesh_terms: D006801:Humans; D008297:Male; D008889:Military Personnel / Q000523:psychology*; D016134:Organizational Policy; D061214:Patient Safety; D010561:Personnel Staffing and Scheduling; D012307:Risk Factors; D059020:Suicidal Ideation; D014481:United States; D055815:Young Adult; D000092864:Suicide Prevention