title: Suicide and Suicide Attempts on Hospital Grounds and Clinic Areas.
abstract: The goal of this study was to describe suicide and suicide attempts that occurred while the patient was on hospital grounds, common spaces, and clinic areas using root cause analysis (RCA) reports of these events in a national health care organization in the United States.
  
  
  
  This is an observational review of all RCA reports of suicide and suicide attempts on hospital grounds, common spaces, and clinic areas in our system between December 1, 1999, and December 31, 2014. Each RCA report was coded for the location of the event, method of self-harm, if the event resulted in a death by suicide, and root causes.
  
  
  
  We found 47 RCA reports of suicide and suicide attempts occurring on hospital grounds, common spaces, or clinic areas. The most common methods were gunshot, overdose, cutting, and jumping, and we have seen an increase in these events since 2011. The primary root causes were breakdowns in communication, the need for improved psychiatric and medical treatment of suicidal patients, and problems with the physical environment.
  
  
  
  Hospital staff should evaluate the environment for suicide hazards, consider prohibiting firearms, assist patients with no appointments, and promote good communication about high-risk patients.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Mills
authors.forename: Bradley V
authors.initials: BV
authors.lastname: Watts
authors.affiliation: From the VA National Center for Patient Safety, White River Junction, VT.
authors.forename: Robin R
authors.initials: RR
authors.lastname: Hemphill
mesh_terms: D006761:Hospitals; D006801:Humans; D060891:Root Cause Analysis; D013406:Suicide, Attempted; D014481:United States / Q000453:epidemiology