Suicide "Prevention" - be careful using absolute terms

Designers, product manufacturers and health care facilities should be very careful with using absolute terms such as suicide “prevention”, tamper “proof”, “anti”- ligature and similar terms from which a reader or listener may infer that a warrantee or guarantee is being given that there is absolutely no way that a patient could use this design, product or facility to harm themselves or others.  These terms suggest an absolute condition.  It is like the old saying about being “a little bit pregnant”.  This is impossible.  Either you are, or you are not. 

If a designer, manufacturer or hospital states that they are going to design something that will “prevent” suicide or “stop” patients from harming themselves or that their facility is suicide “proof”, they are in danger of having a very long day in court sometime in the future.  Attorneys have the benefit of hindsight.  If a patient did actually harm themselves or others using your design or product or while in your facility, then it must not have been good enough and you must have been negligent.  Otherwise this incident would not have happened. 

No, it really isn’t that simple, but the attorney for the plaintiff will try to make it seem that way and you may have a tough time convincing a jury that you really did try. 

What can you do to protect yourself and your company?

I always try to replace “prevent” with “resist”, “anti-ligature” with “ligature resistant”, “tamper-proof” with “tamper-resistant”, etc.  Most, if not all, products and design solutions that are available for use in these facilities are not perfect.  Patients are very good at finding ways to circumvent the designers’ best attempts to keep their buildings and/or products from being used to harm themselves or others.  I am convinced that psychiatric patients are typically well above average intelligence and are very creative in finding ways to harm or kill themselves. 

Just because a product or design is not perfect does not mean that it shouldn’t be used.  If it reduces some of the risk of the more commonly used options, then it should definitely be considered.  As I discussed in a previous blog on this website, every organization needs to determine its tolerance for risk for a large number of design decisions as well as product selections.  The designers need to clearly present the positive as well as negative aspects of each decision so that the organization can make an informed decision that takes into account its risk tolerance with respect to its patient population, staffing pattern, corporate culture and many other elements.  Careful review of these elements by the hospital’s Risk Management and Safety Programs with proper documentation of the reasons why certain conditions were provided may be very helpful if an incident occurs.   

A little attention to careful choices of words may be very helpful in the event of a death by suicide or serious assault on another patient or staff member.  It is kind of like another old saying about computer hard drives crashing.  It is not “if” it will crash, but rather “when” it will crash.  I think that the only way to prevent patients from committing suicide when they have decided to do so is to keep them either physically or chemically restrained 24/7.  That is not treatment.  Anything less is risk management. Unfortunately, suicide and patient to staff injuries are inescapable when working with behavioral health facilities.  If you work with enough of these projects/patients, sooner or later an incident is going to occur.  I am aware of a facility that had a particular type of supply air grille in every patient room.  For 15 years there was no problem.  One night there was a problem and all of the grilles were changed out quickly, but it was too late for one patient.

Data released recently by the Joint Commission shows that the number of inpatient deaths by suicide may be increasing rather rapidly.  Designing a new facility with the same features as a former facility that has served well and without problems for many years could prove to be a serious mistake.  Thinking you don’t need to change things because you haven’t had a serious incident in the past may lead you to a false sense of security.  Many consultations for assessment of patient risk come only after there has been a serious incident.

It is wise to not over-state the degree of resistance your facility, design or product has to harmful activity by patients.  Becoming over confident that serious incidents will not happen in your facility or with your product or design could prove to be a very costly mistake.