Minnesota Hospital Association

Quality & Patient Safety

February 27, 2006

Minnesota Patient Safety Alert: Patient Protection- Suicide by hanging

MDH has reviewed data from the patient safety registry and has noted suicide by hanging via 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, and 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 are highlighted below:

  • 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.

Suggested resources:

The epidemiology and prevention of suicide by hanging: a systematic review. (abstract) http://ije.oxfordjournals.org/cgi/content/abstract/34/2/433