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temporary harm and interventions were required to save the patients life (The Joint Commission,
2016a). These events call for immediate investigation and response, hence the term sentinel
(The Joint Commission, 2016a). Nurses should prevent sentient events from occurring and know
how to respond when one does occur. This paper addresses Sentinel Event Alert 56: Detecting
and treating suicide ideation in all settings from The Joint Commission (2016b). The suicide
prevention program proposed in this paper aims to increase the usage of suicide assessments and
outlines the program plan with a case study, root cause analysis, literature review, and corrective
action plan.
Sentinel Events
Sentinel events cover a wide spectrum of serious adverse events. Examples of sentinel
events include elopement, rape, assault, suicide of any patient receiving care, homicide, wrong
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site surgery, unintended retention of a foreign object after surgery, etc. (The Joint Commission,
2016c). These examples involve the nursing staff because their patients, their jobs, and nursing
license could be jeopardized. The patient could die, be permanently harmed, or severely harmed
temporary. The Joint Commission reviews sentinel events that involve an unanticipated death
and loss of a function not related to the patients underlying condition (The Joint Commission,
2016c). The examples mentioned above are reviewable cases. Hospitals are not required to
report to The Joint Commission but are highly encouraged to (The Joint Commission, 2016c).
The Joint Commission may also be reported to by family members or employees involved in the
sentinel event (The Joint Commission, 2016c). Once The Joint Commission has been contacted,
the hospital is expected to prepare a root cause analysis (RCA) and an action plan within 45 days
of the sentinel event (The Joint Commission, 2016c). The Joint Commission will determine
whether or not the RCA and action plan are acceptable, thorough, and credible (The Joint
Commission, 2016c). Then when the RCA and action plan are approved, The Joint Commission
will schedule an appropriate follow up activity due in four months (The Joint Commission,
2016c). The Joint Commission will also collect and analyze the data to add to their database
(The Joint Commission, 2016c). The database will increase knowledge about sentinel events,
contributing factors, and prevention strategies (The Joint Commission, 2016c). These are the
steps the Joint Commission will act upon when a sentinel event occurs.
Case Study
J.B. is a college senior struggling with major stress and loneliness. As the fall season
approaches, he finds himself feeling more emotional than normal. All his friends graduated the
semester prior, so he has no one there to support him. He turns to painkillers and alcohol to
cope. At 1440, 23 year-old male J.B presents to the emergencies room (ER) for acetaminophen
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(Tylenol) toxicity and acute liver failure (ALF). Acetaminophen toxicity and ALF are the
primary diagnoses. ALF may lead to irreversible brain damage and multi-organ failure
(National Center for Biotechnology Information (NCBI), 2009). Healthcare professionals are
rushing to treat him with oxygen therapy, intravenous (IV) fluid, and N-acetylcysteine (NAC).
However, as J.B. recovers, the primary diagnosis will shift to a diagnosis of major depression.
This shift goes unnoticed. He is discharged from the ER and is relieved to be heading back to his
apartment. His liver recovered from the acetaminophen overdose and he swears to never do that
again. However, the hospital visit set him behind on all his classes. He was unable to catch up
on the lectures, so he failed all his midterms. He feels worthless and still has no one to turn to
for support. He spends the whole night crying in desperation about how he needs to get rid of his
emotional pain. At 0115, J.B. is readmits himself to the hospital because he overdosed on
acetaminophen again. The ER employees start treating the acetaminophen toxicity and ALF
again. However, he swallows more acetaminophen pills from his personal bottle, goes into
for Healthcare Research and Quality (PSNET&AHRQ), 2016). The purpose of RCA is to
identify underlying problems that increase the likelihood of error while avoidingfocusing on
diagram. The suicide prevention program used a Fishbone diagram method to visually represent
the RCA process. The Fishbone diagram is also used to brainstorm the contributing factors
into the ER. The contributing factors leading to the effect are failure to assess for suicide risk,
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absence of a suicide risk assessment policy in the ER, and also a hectic ER environment. Failure
to assess for suicide risk in a suicidal patient increases the rate at which those patients reattempt.
The suicidal patient will not have their mental health diagnosis identified, assessed, or treated.
Absence of a suicide risk assessment policy in the ER leads to the ER doctors and nurses not
assessing for suicide risk. The ER doctors and nurses are unlikely to practice a new assessment
if it is not outlined in a policy. The hectic ER environment causes the employees to overlook
mental health issues in their patients. The ER doctors, nurses, medical technicians, and nursing
assistive personnels (NAPs) are already rushed to do their required tasks, so its doubtful that
they would acknowledge the mental health issues in the patient if the hospital policy doesnt
require them to. These are all the significant contributing factors addressed in the Fishbone
about responses to the prevention of suicide in United States (US) hospital settings. Data
regarding the medical methods are used to assess and treat suicide ideation was summarized.
Studies show that acetaminophen overdoses are a major concern in the ER. Preventive methods
include reoccurring suicide precaution plans, the Brief Symptom Rating Scale (BSRS-5), and the
Attempted Suicide Short Intervention Program (ASSIP). The implementation of these evidence
based preventative methods could be used to detect suicidal patients in hospital settings.
Incidence
Budnitz, Lovegrove, and Crosby (2011) conducted a study to measure the frequency and
risks of unrelated substance abuse acetaminophen overdoses in the ER. Results showed that
most acetaminophen overdoses are self-directed acts of violence acts by 15-24 year olds
(Budnitz et al., 2011). The purpose of a 2011 study by Manthripragada, Zhou, Budnitz,
intention, age, gender, and database reliability. The results revealed that there was an age-
population, with the highest rate (15.7) occurring from 2005 to 2006. Between 1991 and 2006,
(Manthripragada et al., 2011 p.819). This data is useful in determining age incidence in suicide
from acetaminophen overdose. The overall age incidence for suicide is 13-24 year olds.
Assessment
A study conducted by Adams (2013), suggests reducing suicide by developing a suicide
precaution assessment plan. The study reviewed literature on suicide prevention and the general
hospitals. The results revealed that assessment questions and policies are the most beneficial in
preventing suicide. The literature helped initiate a suicide precaution plan for physicians and
nurses. The final suicide precaution plan consists of a set suicidal assessment order for the
physicians and an automated suicidal assessment task set for nurses (Adams, 2013). Gray and
Dihigo (2015) state that assessments are more detailed and determine the level of suicide risk.
Assessment is utilized for the doctors and nurses to decide on the best treatment plan for the
individual (Gray & Dihigo, 2015). Assessment is useful for the hospital setting for determining a
ideation (Wu et al., 2016). The purpose is to detect likelihood of suicide with the Brief Symptom
Rating Scale (BSRS-5) screening tool. This tool is used for psychiatric morbidity and suicide
ideation screening within the general public. The participants were given the BSRS-5, which
include questions such as Do you have any suicide ideation? These questions are rated on a
one to five scale, the higher the score meaning the poorer the participants mental health. The
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results suggest that the screening is effective in detecting suicidal ideation for both the
attempted suicide short intervention program (ASSIP), assessed the effectiveness of ASSIP
reducing suicidal ideation (Gysin-Maillart, Schwab, Soravia, Megert, & Michel, 2016, p.1). The
ASSIP is used in addition to usual the clinical treatment for reducing suicide. Usual clinical
treatment is dependent on the clinicians orders for a specific patient. Study protocol initiated
three therapy sessions followed by regular contact through personalized letters over 24 months
(Gysin-Maillart et al., 2016, p.1). The patients were also asked to complete questionnaires about
the study every six months in order to evaluate the intervention. The results showed that ASSIP
reduced repeated suicide attempts by 80%. ASSIP is also a low-cost and easy to use intervention
(Gysin-Maillart et al., 2016). Gray and Dihigo (2015) also state that suicide risk screening tools
are brief and easy to perform. They are normally used for lower risked individuals (Gray &
Dihigo, 2015). These tools are effective in screening for suicide when used in conjunction with
ER. There are many studies covering various suicide precaution plans. The most effective
precaution plan includes suicide assessments from both the physician and the nurse. Recent
studies introduce tools such as the BSRS-5 and the ASSIP. Data suggests that these suicide
assessments and new tools are effective in detecting suicide ideation and reducing attempts.
Corrective Action Plan
A corrective action plan is a step by step plan of action that is developed to achieve
targeted outcomes for resolution of identified errors (Centers for Medicare and Medicaid
Services (CMS), 2013). The corrective action plan includes cost-effective actions, an
stakeholders involved in this plan are physicians, nurses, ER staff, hospital administrators,
psychiatrists, psychologists, suicide attempted survivors, and families. These stakeholders are
invested in the development, implementation, and evaluation of the corrective action plan. Nine
employees will comprise the suicide prevention team. The ER nurse manager and the program
leader will recruit the team members. The board will be made up of an ER nurse manager, a
program leader, a mental health counselor, mental health nurses, and champions.
Problem Statement, Goal and Objectives
In 2011, the number of ER visits in the U.S. due to suicide attempts were 836,000, and in
2014 suicide is listed number 10 on the cause of death rank (Centers for Disease Control and
Prevention (CDC), 2016a). These numbers of suicides need to be reduced. The goal is to
increase usage of suicide assessments in the ER by 99% in one year. The first objective is to
increase the awareness of suicide and their risk factors to the ER nurses by 95%. This will be
achieved by identifying the ER staff that needs to be trained, developing a curriculum, training of
the champions, evaluation of the champions, and monitoring the impact. The second objective is
to increase awareness and training of suicide prevention strategies and policy to the ER nurses by
95%. This will be completed by identifying the ER staff that need to be trained, developing
suicide assessment guidelines and policies, training of champions, evaluating the training, and
monitoring the impact. The third objective is reducing the stigma of suicidal patients among the
ER nurses by 95%. This will be accomplished by identifying the ER staff that need the training,
Network of Libraries of Medicine (NNLM), n.d.). The logic model provides a framework for the
planning, implementation, and evaluation of the suicide prevention program. The logic model is
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presented in Appendix B. The overall goal is to increase the usage of suicide assessments in the
ER by 99% in one year. The approach involves mental health experts, which are mental health
nurses and a mental health counselor, to conduct a training of champions. The champions are
hospital employees who will teach the information to their fellow staff members. The trained
champions will then take charge of the in-services at the hospital. Education topics will include
suicide, suicide risk factors, suicide prevention strategies, and the stigma affecting suicidal
patients. The first in-service will teach suicide and suicide risk factors. The second in-service
will teach about suicide prevention strategies and policy. The third in-service will teach about
reducing the stigma affecting suicidal patients. The in-services will span over three months and
there is one mandatory class each week. Appropriate informational pamphlets will be distributed
to each employee after the in-services. Evaluation and reevaluation of the program will be done
in the seventh to ninth months. The evaluation is to assess whether or not the in-services
increased the awareness of suicide and their risk factors, increased knowledge of suicide
prevention strategies and policy, and reduced the stigma of suicidal patients.
Change Strategy
The suicide prevention program will utilize the Lewins Change Model. The Lewins
Change Model describes the basic stages of the change process, which includes the stages of
unfreezing, change, and refreezing (Lewin, 1951). The unfreezing stage is the actions used to
increase readiness for change. The change stage is the actions that need to be done in order for
the change to happen. The refreezing stage is the stage in which the change becomes the new
norm (Lewin, 1951). The suicide prevention program will unfreeze by initiating suicide
awareness. It will start change by teaching and training the ER staff about how to assess for
suicide risk factors, how to use suicide prevention strategies, and how to implement the suicide
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prevention policy. It will refreeze by educating about reducing the stigma and practicing the
policy.
Implementation Plan
The implementation plan is a detailed accounting of how the suicide prevention program
plans to present this project. The work plan is outlined in Appendix C. The timeframe of the
suicide prevention plan is from January 2017 to January 2018. Initially, the program will meet
with key stakeholders, identify champions, and form the task group. Then the task force will
identify the proposal, present the proposal, budget for approval, and request funding. The task
force will meet monthly for updates and evaluations. The champion training will last three
months and the champions will have classes twice a week with the mental health experts. Then
the champion training will be reevaluated within two months. The in-services of suicide
awareness and risk factors, suicide prevention strategies and policy, and suicide stigma will span
over a three-month period. The in-services will be evaluated during the training months, in the
beginning and end of each month. By the last month, the task force will meet with key
consultant costs, equipment, supplies, and other costs. A proposed annual budget total of
$30,363.28 will be required to implement the corrective action plan. This will include salaries
for the nurse managers, mental health counselor, mental health nurses, and champions. A total of
$9,038.40 will be needed for total direct staff costs. These costs include the hourly rate for the
champions to conduct the training, the champion training evaluation hours, and all the in-service
hours for the champions and ER nurses. An additional $3,764.88 will be allocated for consultant
costs, and this is used when the program needs exerts to advise in reevaluations. Additionally,
$1,700.00 will be requested for equipment of laptops, a projector, and simulation lab. The
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supplies will total to about $260.00 for teaching packets, pre and post surveys, and pamphlets.
Both the equipment and the supplies will be necessary when conducting the in-services. The
assessments in the ER by 99% in one year. The evaluation plan will include evaluation of the
champion training, in-services, and the effectiveness of the overall program. The champion
training evaluation will take place within two months. By the second month, the champions will
be evaluated for how effective their teaching is. The champions will teach to the evaluators as
they would to the ER employees. The evaluators will then assess whether or not the champions
are ready to teach the in-services. If the champions are not ready, then the evaluators will re-
evaluate the training. The in-service training will be evaluated with pre and post-tests. The pre
and post-test will determine whether or not the in-services were effective. By the end of the
year, the program will be evaluated via compilation of data collected throughout the program.
During this time, the goal of increasing the use of suicide assessments in the ER will be
determined as either effective or ineffective. If the program is ineffective, then the program
administrators, managers, and task force will re-evaluate the curriculum and training. However,
the program was proven to be effective. The program reached its goal with a 99% increase in the
usage of suicide assessments in the ER within one year. The pre-test for the first in-service was
50%, the pre-test for the second in-service was 25%, and the pre-test for the third in-service was
20%. All the post-tests were met with 95% within one year. The findings and results will be de-
identified before dissemination. Dissemination of these findings will be shared with the hospital,
key stakeholders, and other hospitals with the same management. It will be disseminated
through posters and handouts throughout all the hospitals nursing offices, employee locker
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rooms, and break rooms. This will allow the employees to readily access the findings throughout
the hospital.
The CAP was effective in reaching the goals and objectives of the suicide prevention
plan. It was also adequate in outlining what those goals and objectives were. The logic model
and the Lewins Change Model framed the suicide prevention plan to success. The
implementation plan was efficient in keeping the program on time with their detailed accounting.
The budget proposal and evaluation plan also keeps the plan on track, but with finance and
measuring effectiveness.
In 2014, suicide was the listed number 10 on the cause of death ranking (CDC, 2016a).
Suicide in the ER is a sentinel event that should never be overlooked. The suicide prevention
team concluded that the absence of a suicide assessment and policy were the main causes leading
up to J.B.s suicide. Suicide assessments are key in reducing the incidence of suicide. The
suicide prevention team implemented three in-service courses to increase the usage of suicide
assessments by 99%. The ER staffs knowledge of suicide, risk factors, suicide prevention
strategies, policy, and stigma also reached the programs objectives. The suicide prevention plan
was effective and will be shared with the hospital, key stakeholders, and other hospitals with the
same management.
References
Adams, N. (2013). Developing a suicide precaution procedure. MEDSURG Nursing, 22(6), 383-
386
Budnitz, D., Lovegrove, M., & Crosby, A. (2011). Emergency department visits for overdoses of
585592. http://dx.doi.org.libproxy.csustan.edu/10.1016/j.amepre.2011.02.026
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Centers for Disease Control and Prevention (CDC). (2016a). Suicide and self-inflicted injury.
http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html
Centers for Medicare and Medicaid Services (CMS). (2013). Corrective action plan (CAP)
Data-and-Systems/Monitoring-
Programs/PERM/Downloads/2013correctiveActionPowerpoint.pdf
Gray, B. P., & Dihigo, S. K. (2015). Suicide risk assessment in high-risk adolescents. Nurse
therapy for patients who attempt suicide: A 24-months follow-up randomized controlled
study of the attempted suicide short intervention program (ASSIP). Plos Medicine, 13(3),
1-21. doi:10.1371/journal.pmed.1001968
Lewin, K. (1951). Field theory in social science: Selected theoretical papers. New York: Harper
& Row.
Manthripragada, A. D., Zhou, E. H., Budnitz, D. S., Lovegrove, M. C., & Willy, M. E. (2011).
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504411/
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Patient Safety Network & Agency for Healthcare Research and Quality (PSNET&AHRQ).
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The Joint Commission. (2016a). Sentinel event policy and procedures. Retrieved November 6,
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The Joint Commission. (2016c). Sentinel Event policy and procedures by accreditation and/or
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Wu, C., Lee, J., Lee, M., Liao, S., Chang, C., Chen, H., & Lung, F. (2016). Predictive validity of