By Larry Lacombe

Patient suicide ranks among the top three sentinel events, reports The Joint Commission (TJC), prompting regulators to focus heavily on ligature risks this year. If many suicide attempts are impulsive, TJC reasons, then reducing environmental risks and opportunities for self-harm is vital for curbing the suicide trend in health care settings.

With that in mind, surveyors are taking a hard look at ligatures: potential hanging or choking points in health care facilities. Patients who have been identified as a potential risk to themselves or others, will use any item or ligature point within a room to accomplish harm. Additionally, some accreditation organization surveyors have gone to extremes to validate a point of view by utilizing floss, hanging it over a door hinge and saying, “That’s a ligature point.” Although that example may be extreme, the fact is that accreditation organizations are being extremely meticulous, which means health care facilities must ensure they are prepared for this type of scrutiny.



Any observable ligature risk, no matter how small, is an immediate "Recommendations for Improvement" (RFI) when observed in an inpatient psychiatric area, to be corrected within 45 days or less depending on the severity or the total number of issues identified. Given what’s at risk – people’s lives – ligature RFIs are never appropriate for time extensions, said the TJC at this year’s ASHE conference.

Put simply, when surveyors walk into your health care facility, they’ll assess:

• Has this facility identified and assessed ligature risks?
• What plans have they developed to eliminate those risks?
• What is their risk assessment process?
• Is staff aware, trained and well equipped to act on these plans and improvement processes?

In a recent alert, TJC outlined minimum expectations for ligature risk mitigation plans:

• Leadership and staff are aware of current environmental risks.
• Patient’s individual risk for suicide or self-harm is identified, followed by appropriate interventions.
• At-risk behavior is assessed on a recurring basis.
• Staff is properly trained to identify patients’ level of risk and intervene properly.
• Suicide and self-harm mitigation strategies are incorporated into the Quality Assessment/Performance Improvement (QAPI) program.
• Policies and procedures are in place, and staff knows what immediate action to take when a patient is deemed at risk for suicide.
• If equipment poses a risk but is necessary for treatment of psychiatric patients, those risks are considered in the patient’s assessments, and adequate interventions are implemented to minimize those risks.

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