Checklist of Environmental Hazards Helps Reduce Inpatient Suicides in VAMCs

Peter Mills, PhD, director of the VA National Center for Patient Safety Field Office

By Sandra Basu


WASHINGTON — When receiving care in a hospital, suicidal patients could take advantage of anything from bedding to belts to kill themselves.

That’s how usually harmless objects become “environmental hazards” and why they should be considered in efforts to keep suicidal patients safe in the inpatient setting, according to Peter Mills, PhD, director of the VA National Center for Patient Safety Field Office.

Mills spoke at the 2012 DoD/VA Suicide Prevention Conference about how addressing potential suicide hazards can decrease hospital suicides. He offered data showing how successful a mandatory checklist of those items has been for the VHA.

About 1,500 hospital inpatient suicides occur in U.S. hospitals each year, he said.

In terms of the suicide rates at VAMCs, Mills used required root-cause analysis reports to determine that, between December 1999 and December 2011, there were 471 attempted suicides in VHA facilities with 65 completed. About 45% of the completed suicides and half of all attempts took place in inpatient psychiatry units.

“It is not just a psychiatric unit problem, but is all over the hospital,” Mills said.


According to his presentation, hanging is the most common method for inpatient suicides in the VHA, though reports of overdose and cutting are more prevalent on medical units, domiciliaries and nursing home care units. Sheets and bedding continue to be the most commonly used items for hangings.

The VHA has developed a checklist that mental health staff in VHA psychiatric units can use to identify environmental hazards that could facilitate suicides. The Mental Health Environment of Care Checklist (MHEOCC) includes 114 items and asks questions such as whether beds are free of anchor points for hanging and whether vents in the ceiling are designed so they cannot serve as an anchor point for hanging.

The checklist became mandatory in 2007 in all VHA mental health units treating suicidal patients.

In a 2010 study, Mills and his colleagues found that, during the first year of implementation of the checklist, the 113 mental health units in VA facilities identified and rated 7,642 hazards. Because of the checklist, 5,834 (76.3%) of these hazards had been addressed by facilities at the end of the first year.

“We found that anchor points capable of sustaining the weight of a patient attempting to hang him- or herself in bedrooms and bathrooms were the most common and dangerous identified hazards,” the study authors wrote.

A new study by Mills and his colleagues published in the June issue of the Archives of General Psychiatry suggests that the implementation of the Mental Health Environment of Care Checklist is associated with a reduction in the rate of completed inpatient suicides in VHA hospitals, noting, “Our review of the RCA database revealed 25 completed suicides that occurred on VHA inpatient mental health units between January 1, 1999, and March 31, 2011. Twenty-two suicides occurred prior to implementation of the MHEOCC (1999-2007), and 3 occurred after (2008-2011).”

The authors wrote that the “rate of suicide was 2.64 per 100,000 inpatient mental health admissions before use of the MHEOCC, and it decreased to 0.87 per 100,000 admissions after MHEOCC.”

Only suicides occurring on mental health units were included in the study. The authors wrote that the study “builds on the existing outpatient literature suggesting that environmental alterations alone can be associated with reduction in suicides.”

Still, the authors did note limitations to the study, including that, without a group of control hospitals, they “cannot say for certain that reduction in inpatient suicides was due to use of the MHEOCC and not some other unknown factor.”

  • Inpatient Suicide in VA Hospitals
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1: Mills PD, Watts BV, Miller S, Kemp J, Knox K, DeRosier JM, Bagian JP. A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf. 2010 Feb;36(2):87-93. PubMed PMID: 20180441.

1: Watts BV, Young-Xu Y, Mills PD, Derosier JM, Kemp J, Shiner B, Duncan WE. Examination of the Effectiveness of the Mental Health Environment of Care Checklist in Reducing Suicide on Inpatient Mental Health Units Mental Health Environment of Care Checklist. Arch Gen Psychiatry. 2012 Jun 1;69(6):588-92. PubMed PMID: 22664548.


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