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Elsevier Clinical Skills

Suicide: Environmental Safety Assessment and Management (Mental and Behavioral Health) - CE


The physical environment has been implicated in a majority of reported inpatient suicides.4 Hanging has been the most common cause of completed suicide in the inpatient setting.12


Suicide is a leading cause of death in the United States.7 Although many suicides occur outside of health care facilities, other suicides do occur within acute care settings, including inpatient psychiatric settings. Safe inpatient environments and excellent care for all patients is more likely to decrease suicide risk than attempts to identify high-risk patients.4,9,11 Identifying patients who are at risk is important; however, relying on interventions such as no-suicide contracts lack empirical evidence and provide no assurances of a lack of suicidal intent.3

Specific actions to minimize risk of suicide in an inpatient psychiatric setting involve having ligature-resistant features in all areas accessible to patients. These are areas in which a cord or bedsheet cannot be looped or tied for a sustained time and result in self-harm or loss of life. Other actions include having an unobstructed view from the station where health care team members work of areas accessible to patients, having solid ceilings (dropped ceilings are a ligature risk), having ligature-free hardware on doors, and having health care team members present for bathroom access if the bathroom cannot be made ligature resistant.

The health care team needs to regularly assess the environment to identify environmental risks. A standardized tool such as the Mental Health Environment of Care Checklist (MHEOCC)10 can facilitate health care team members’ environmental safety assessment. Environmental risks on the behavioral health unit level include ligature points, cleaning solutions, or lanyards. Patients’ belongings, including drawstrings, belts, shoelaces, or sharp items, may also present risks. The health care team should remove items judged to be a risk and work closely with other team members to identify the appropriate level of observation. Restricting access to lethal means is an important part of comprehensive suicide-prevention program.6


  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Establish a rapport with the patient, family, and designated support person that encourages questions. Answer them as they arise.
  • Consider the patient’s, family’s, and designated support person’s values and goals in the decision-making process.
  • Assist the patient, family, and designated support person to recognize signs and symptoms of acute exacerbation of the illness, including heightened risk of suicide or self-harm.
  • Explain the manifestations of the illness and expected progression of symptoms if the patient experiences a relapse. Describe what the family and designated support person are likely to see, hear, and experience (e.g., a behavioral health unit precautions to prevent suicide, frequent observations, possible restrictions on personal items). Advise the patient, family, and designated support person of steps to take if relapse occurs.
  • Explain to the patient, family, and designated support person that the main goal is to provide a safe, secure place to receive treatment.
  • Explain how the behavioral health unit may be different than other settings. Interaction is promoted between patients and staff, and group meetings are encouraged. To ensure patients’ safety, they are checked on frequently throughout the day.
  • Educate the family and designated support person regarding the nature of psychiatric illness and signs and symptoms (e.g., psychological pain; direct and indirect indications of suicidal thoughts; plans and intent that may indicate suicide risk, such as expressing a desire to die or giving away prized possessions).
  • Assist the patient, family, and designated support person to engage and participate as drivers of the plan of care.
  • Explain the importance of following the medication regimen as ordered. The patient should not alter dosage or stop taking the medication even if symptoms have subsided and he or she is feeling better.
  • Explain that access to personal items such as razors and belts may be restricted or require monitoring when accessed.
  • Instruct the family and designated support person to refrain from bringing items that may be dangerous (e.g., belts, shoelaces, sharp items, medications) to the behavioral health unit.
  • Give the patient, family, and designated support person phone numbers to suicide-prevention resources.


  1. Perform hand hygiene.
  2. Introduce yourself to the patient, family, and designated support person.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient’s mental status and ability to understand information and participate in decisions. Include the patient as much as possible in all decisions.
  5. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.8 An example of a frequently used standardized tool is the Columbia-Suicide Severity Rating Scale (C-SSRS).5
  6. Evaluate the patient’s, family’s, and designated support person’s understanding of the patient’s illness.
  7. Assess and discuss the patient’s goal for treatment.
  8. Collaborate with the patient, family, and designated support person to develop a plan of care.
  9. Identify the patient’s psychiatric advance directives, if available.
  10. Determine the patient’s desire for the family or designated support person to be kept informed and involved in treatment.
  11. Determine the family’s or designated support person’s ability to support the patient during treatment.


  1. Perform hand hygiene.
  2. Verify the correct patient using two identifiers.
  3. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.8 If homicidal or suicidal ideation is present, implement appropriate precautions based on the patient's status.
  4. Explain the strategies to the patient, family, and designated support person and ensure that they agree to treatment.
  5. Maintain a calm, collaborative communication approach, avoiding the use of coercion.
  6. Create an environment of trust that allows development of a therapeutic relationship.
  7. Orient the patient to the unit. Include discussion of unit routines, guidelines, patients’ rights and expectations, and schedules. Inform the patient that he or she will be checked on frequently throughout the stay.
  8. Create an environment that advocates for the patient’s needs using an interdisciplinary team. Engage the team in collaborative assessment and treatment planning with the patient.
  9. Engage the patient in treatment, including participation in therapeutic groups and individual sessions.
  10. Administer psychiatric medications as ordered and monitor the patient’s response to the medications.
  11. Monitor the patient’s responses and social interactions in the milieu; reinforce appropriate social skills.
  12. Implement appropriate precautions based on the patient’s status.
  13. Respond to crisis in calm, therapeutic, and nonthreatening manner. Use the least restrictive interventions to prevent harm to patients or staff.
  14. Collaborate with the patient, family, designated support person, and team in planning for patient discharge and follow-up care.
  15. Provide the appropriate education related to medications, crisis management, and follow-up care to the patient, family, and designated support person at the time of discharge.
  16. Explain to the patient, family, and designated support person that ongoing treatment is vital to continuing recovery. Making and keeping follow-up appointments is critical.
  17. Conduct an environmental safety assessment to identify features in the behavioral health unit that a patient can use to attempt suicide.1
    1. Identify environmental hazards on the unit such as ligature anchor points, hinges, and hooks, and areas where visual observation is obscured.
    2. Identify patient belongings that may present a hazard such as belts, shoelaces, and sharp items.
    3. Identify other factors that may indicate a high risk of suicide such as hoarding of towels or linen and missing unit recreational activities equipment or tools.
  18. Take steps to mitigate the risks identified in the environmental safety assessment if the patient is at risk of using these items for self-harm.7 Remove or modify access to potentially harmful items that may be used for suicide.1
    1. Hooks, shoelaces, and belts that can be used for hanging
    2. Plastic bags that can be used for suffocation
    3. Medications and cleaning fluids that can be ingested
    4. Razors, mirrors, compact discs (CDs), and other sharp objects that can be used for cutting
  19. Keep health care team members informed about anything that could be a suicide risk.3
  20. Check visitors and search items brought into the environment to remove potentially harmful items.11
  21. Collaborate with the health care team to determine the level of supervision needed for the patient.
  22. Participate in routine environmental rounds.
  23. Perform hand hygiene.
  24. Document the strategies in the patient’s record.


  1. Reassess the patient’s pain status and provide appropriate pain management (e.g., medication, relaxation, mindfulness skills).
  2. Monitor the patient’s suicide risk using a standardized tool, such as the C-SSRS.
  3. Monitor environmental risks using a standardized assessment tool, such as the MHEOCC.


  • Environmental hazards are minimized.
  • Patient remains safe and free from self-harm.


  • Significant environmental hazards are present in the environment.
  • Patient attempts or commits self-harm.


  • Education
  • Patient’s behaviors and response to interventions
  • Patient’s progress toward goals
  • Assessment of pain, treatment if necessary, and reassessment
  • Suicide risk assessment and interventions
  • Level of observation


  • Suicidality is a leading cause of inpatient admission for adolescents, and suicide and self-harm behaviors commonly continue during adolescents’ inpatient stay. Currently there are no clinical guidelines or strategies that have demonstrated effectiveness in reducing these behaviors;2 therefore, maintaining a safe environment for this population is essential.


  • Older adults may require equipment such as wheelchairs, hospital beds, walkers, or continuous positive airway pressure machines with tubing that present ligature risks.


  1. American Psychiatric Nurses Association (APNA). (2015). Psychiatric-mental health nurse essential competencies for assessment and management of individuals at risk for suicide. Retrieved July 6, 2020, from https://www.apna.org/files/public/Resources/Suicide%20Competencies%20for%20Psychiatric-Mental%20Health%20Nurses(1)(1).pdf (Level VII)
  2. Amitai, M. and others. (2019). Predictors of suicidal behaviors during hospitalization among adolescents admitted due to suicidal behaviors: A 10-year retrospective naturalistic study. Archives of Suicide Research, 1-15. Epub ahead of print. doi:10.1080/13811118.2019.1586610 Retrieved July 6, 2020, from https://www.tandfonline.com/doi/full/10.1080/13811118.2019.1586610 (Level VI)
  3. Bryan, C.J. and others. (2017). Effect of crisis response planning vs. contracts for safety on suicide risk in US Army soldiers: A randomized clinical trial. Journal of Affective Disorders, 212, 64-72. doi:10.1016/j.jad.2017.01.028 (Level II)
  4. Canady, V. A. (2018). Joint Commission releases first data-driven estimate of US hospital suicides. Mental Health Weekly, 28(35), 1-3. doi:10.1002/mhw.31589 (Level VI)
  5. Interian, A. and others. (2018). Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) to classify suicidal behaviors. Archives of Suicide Research, 22(2), 278-294. doi:10.1080/13811118.2017.1334610 (Level VI)
  6. Joint Commission, The. (2017). Special report: Suicide prevention in health care settings recommendations regarding environmental hazards for providers and surveyors. Retrieved July 6, 2020, from https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/suicide-prevention/november_perspectives_suicide_risk_reduction.pdf?db=web&hash=236585A71D0B5B2D0DAB5DBBB8BA8EE6 (Level VII)
  7. Joint Commission, The. (2019). R3 report: National Patient Safety Goal for suicide prevention. Retrieved July 6, 2020, from https://www.jointcommission.org/assets/1/18/R3_18_Suicide_prevention_HAP_BHC_5_6_19_Rev5.pdf (Level VII)
  8. Joint Commission, The. (2020). National patient safety goals. Behavioral health care accreditation program. Retrieved July 6, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_bhc_jul2020.pdf (Level VII)
  9. Large, M. and others. (2018). Suicide risk assessment among psychiatric inpatients: A systematic review and meta-analysis of high-risk categories. Psychological Medicine, 48(7), 1119-1127. doi:10.1017/S0033291717002537 (Level I)
  10. U.S. Department of Veterans Affairs (VA). (2018). Mental health environment of care checklist (MHEOCC). Environmental Programs Service Mental Health Guide. Retrieved July 6, 2020, from https://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp (Level VII)
  11. Watts, B.V. and others. (2017). Sustained effectiveness of the mental health environment of care checklist to decrease inpatient suicide. Psychiatric Services, 68(4), 405-407. doi:10.1176/appi.ps.201600080
  12. Williams, S.C. and others. (2018). Incidence and method of suicide in hospitals in the United States. The Joint Commission Journal on Quality and Patient Safety, 44(11), 643-650. doi:10.1016/j.jcjq.2018.08.002 (Level VII)


Joint Commission, The. (2018). Suicide prevention resources to support Joint Commission accredited organizations implementation of NPSG 15.01.01. Retrieved July 6, 2020, from https://www.jointcommission.org/assets/1/18/Suicide_Prevention_Resources_to_support_NPSG150101_Nov201821.PDF

Hunt, J.M., Sine, D.M., McMurray, K.N. (2019). Behavioral health design guide (9th ed.). Retrieved July 6, 2020, from https://fb708656-5e29-4908-8b3f-76a7eb2f68c4.filesusr.com/ugd/038373_4d3f238d61f740858728472abfc90265.pdf

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports