MDH has reviewed data from the patient safety registry and has noted suicide by hanging
door hardware. A review of these events shows two common root causes:
1. environment and equipment;
2. staff training and education of suicide assessments and precautions.
Nationally, inpatient suicide by hanging mostly occur in bathrooms, bedrooms, or closets
and have occurred in psychiatric facilities, acute care hospitals, residential care facilities,
in emergency rooms.
A large percentage of
all hanging suicides are not fully suspended, meaning the ligature points (beams, hooks, banisters) are below head level.
Staff training and education of suicide assessments and precautions
The Joint Commission International Center for Patient Safety lists strategies for
improving patient suicide risk assessments and staff education, and
Use a standardized suicide risk assessment/reassessment procedure
- Implement education for family/ friends regarding suicide risk factors
- Enhance staff orientation/education regarding suicide risk factors
MDH recommends that all facilities, especially those with behavioral health units, review
their environmental and patient safety policies regarding patient suicide prevention,
assess the knowledge of relevant staff of suicide risk factors, and review suicide risk assessment /reassessment procedures.
The epidemiology and prevention of suicide by hanging: a systematic review. (abstract)