Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention

REFERENCES

• Ahmedani, B. K., Westphal, J., Autio, K., Elsiss, F., Peterson, E. L., Beck, A., … Lynch, F. (2019). Variation in patterns of health care before suicide: A population case-control study. Preventive Medicine, 127, 105796.
   PubMed Web of Science ®Google Scholar
• Anderson, J. E., Kodate, N., Walters, R., & Dodds, A. (2013). Can incident reporting improve safety? Healthcare practitioners’ views of the effectiveness of incident reporting. International Journal for Quality in Health Care, 25(2), 141–150. 10.1093/intqhc/mzs081
   PubMed Web of Science ®Google Scholar
• Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. doi:10.1080/1364557032000119616
   Google Scholar
• Barker, I., Steventon, A., & Deeny, S. R. (2017). Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: Cross sectional study of routinely collected, person level data. BMJ 356, j84. doi:10.1136/bmj.j84
   PubMed Web of Science ®Google Scholar
• Bates, D. W., & Singh, H. (2018). Two decades since to err is human: An assessment of progress and emerging priorities in patient safety. Health Affairs, 37(11), 1736–1743. doi:10.1377/hlthaff.2018.0738
   PubMed Web of Science ®Google Scholar
• Berg, S. H., Rortveit, K., & Aase, K. (2017). Suicidal patients’ experiences regarding their safety during psychiatric in-patient care: A systematic review of qualitative studies. BMC Health Services Research, 17(1), 73. doi:10.1186/s12913-017-2023-8
   PubMed Web of Science ®Google Scholar
• Berg, S. H., Rørtveit, K., Walby, F. A., & Aase, K. (2020). Safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis: Qualitative study of patient experiences. BMJ Open, 10(11), e040088. doi:10.1136/bmjopen-2020-040088
   PubMed Web of Science ®Google Scholar
• Bergqvist, E., Probert-Lindström, S., Fröding, E., Palmqvist-Öberg, N., Ehnvall, A., Sunnqvist, C., … Westrin, Å. (2022). Health care utilisation two years prior to suicide in Sweden: A retrospective explorative study based on medical records. BMC Health Services Research, 22(1), 1–10. doi:10.1186/s12913-022-08044-9
   PubMed Web of Science ®Google Scholar
• Bouwman, R., de Graaff, B., de Beurs, D., van de Bovenkamp, H., Leistikow, I., & Friele, R. (2018). Involving patients and families in the analysis of suicides, suicide attempts, and other sentinel events in mental healthcare: A qualitative study in The Netherlands. International Journal of Environmental Research and Public Health, 15(6), 1104. doi:10.3390/ijerph15061104
   PubMed Web of Science ®Google Scholar
• Bowers, L., Dack, C., Gul, N., Thomas, B., & James, K. (2011). Learning from prevented suicide in psychiatric inpatient care: An analysis of data from the National Patient Safety Agency. International Journal of Nursing Studies, 48(12), 1459–1465. doi:10.1016/j.ijnurstu.2011.05.008
   PubMed Web of Science ®Google Scholar
• Braithwaite, J., Wears, R. L., & Hollnagel, E. (2015). Resilient health care: Turning patient safety on its head. International Journal for Quality in Health Care, 27(5), 418–420. 10.1093/intqhc/mzv063
   PubMed Web of Science ®Google Scholar
• Care Quality Commission. (2016). Learning from serious incidents in NHS acute hospitals. A review of the quality of investigation reports. Stratford: Care Quality Commission.
   Google Scholar
• Chock, M. M., Lin, J. C., Athyal, V. P., & Bostwick, J. M. (2019). Differences in health care utilization in the year before suicide death: A population-based case-control ctudy. Mayo Clinic Proceedings, 94(10), 1983–1993. doi:10.1016/j.mayocp.2019.04.037
   PubMed Web of Science ®Google Scholar
• de Kam, D., Kok, J., Grit, K., Leistikow, I., Vlemminx, M., & Bal, R. (2020). How incident reporting systems can stimulate social and participative learning: A mixed-methods study. Health Policy, 124(8), 834–841. 10.1016/j.healthpol.2020.05.018
   PubMed Web of Science ®Google Scholar
• Dixon-Woods, M., & Pronovost, P. J. (2016). Patient safety and the problem of many hands. BMJ Quality & Safety, 25(7), 485–488. doi:10.1136/bmjqs-2016-005232
   PubMed Web of Science ®Google Scholar
• Doupnik, S. K., Rudd, B., Schmutte, T., Worsley, D., Bowden, C. F., McCarthy, E., … Marcus, S. C. (2020). Association of suicide prevention interventions with subsequent suicide attempts, linkage to follow-up care, and depression symptoms for acute care settings: A systematic review and meta-analysis. JAMA Psychiatry, 77(10), 1021–1030. doi:10.1001/jamapsychiatry.2020.1586
   PubMed Web of Science ®Google Scholar
• Elfström, J. (2009). [Incident analyses in healthcare should be sharpened and involve physicians]. Lakartidningen, 48/2009.
   Google Scholar
• Fortin, G., Ligier, F., Van Haaster, I., Doyon, C., Daneau, D., & Lesage, A. (2021). Systematic suicide audit: An enhanced method to assess system gaps and Mobilize leaders for prevention. Quality Management in Health Care, 30(2), 97–103. 10.1097/qmh.0000000000000302
   PubMed Web of Science ®Google Scholar
• Fröding, E., Gäre, B. A., Westrin, Å., & Ros, A. (2021). Suicide as an incident of severe patient harm: A retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective. BMJ Open, 11(3), e044068. doi:10.1136/bmjopen-2020-044068
   PubMed Web of Science ®Google Scholar
• Gillies, D., Chicop, D., & O’Halloran, P. (2015). Root cause analyses of suicides of mental health clients. Crisis, 36(5), 316–324. doi:10.1027/0227-5910/a000328
   PubMedGoogle Scholar
• Hagley, G., Mills, P. D., Watts, B. V., & Wu, A. W. (2019). Review of alternatives to root cause analysis: Developing a robust system for incident report analysis. BMJ Open Quality, 8(3), e000646.
   PubMedGoogle Scholar
• Hawton, K., Appleby, L., Platt, S., Foster, T., Cooper, J., Malmberg, A., & Simkin, S. (1998). The psychological autopsy approach to studying suicide: A review of methodological issues. Journal of Affective Disorders, 50(2–3), 269–276.
   PubMed Web of Science ®Google Scholar
• Hawton, K., & Pirkis, J. (2017). Suicide is a complex problem that requires a range of prevention initiatives and methods of evaluation. The British Journal of Psychiatry, 210(6), 381–383.
   PubMed Web of Science ®Google Scholar
• Hawton, K., & van Heeringen, K. (2009). Suicide. Lancet, 373(9672), 1372–1381. doi:10.1016/S0140-6736(09)60372-X
   PubMed Web of Science ®Google Scholar
• Hofstra, E., Van Nieuwenhuizen, C., Bakker, M., Özgül, D., Elfeddali, I., de Jong, S. J., & van der Feltz-Cornelis, C. M. (2020). Effectiveness of suicide prevention interventions: A systematic review and meta-analysis. General Hospital Psychiatry, 63, 127–140. doi:10.1016/j.genhosppsych.2019.04.011
   PubMed Web of Science ®Google Scholar
• Hollnagel, E., Wears, R. L., & Braithwaite, J. (2015). From Safety-I to Safety-II: A white paper. Published simultaneously by the University of Southern Denmark. Australia: University of Florida, USA, and Macquarie University, Australia: The Resilient Health Care Net.
   Google Scholar
• Hutchinson, A., Coster, J., Cooper, K., McIntosh, A., Walters, S., Bath, P., … Nicholl, J. (2010). Assessing quality of care from hospital case notes: Comparison of reliability of two methods. Quality and Safety in Health Care, 19(6), e2–e2.
   PubMedGoogle Scholar
• Ishimo, M.-C., Sampasa-Kanyinga, H., Olibris, B., Chawla, M., Berfeld, N., Prince, S. A., … Lang, J. J. (2021). Universal interventions for suicide prevention in high-income Organisation for Economic Co-operation and Development (OECD) member countries: A systematic review. Injury Prevention, 27(2), 184–193. doi:10.1136/injuryprev-2020-043975
   PubMed Web of Science ®Google Scholar
• Isometsä, E. (2001). Psychological autopsy studies–a review. European Psychiatry, 16(7), 379–385. doi:10.1016/S0924-9338(01)00594-6
   PubMed Web of Science ®Google Scholar
• Janofsky, J. S. (2009). Reducing inpatient suicide risk: Using human factors analysis to improve observation practices. Journal of the American Academy of Psychiatry and the Law Online, 37(1), 15–24.
   PubMed Web of Science ®Google Scholar
• Klonsky, E. D., & May, A. M. (2015). The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy, 8(2), 114–129. doi:10.1521/ijct.2015.8.2.114
   Web of Science ®Google Scholar
• Klonsky, E. D., Pachkowski, M. C., Shahnaz, A., & May, A. M. (2021). The three-step theory of suicide: Description, evidence, and some useful points of clarification. Preventive Medicine, 152(Pt 1), 106549.
   PubMedGoogle Scholar
• Lang, S., Garrido, M. V., & Heintze, C. (2016). Patients’ views of adverse events in primary and ambulatory care: A systematic review to assess methods and the content of what patients consider to be adverse events. BMC Family Practice, 17(1), 6–9.
   PubMedGoogle Scholar
• Leape, L. L. (2002). Reporting of adverse events. The New England Journal of Medicine, 347(20), 1633–1638. 10.1056/NEJMNEJMhpr011493
   PubMed Web of Science ®Google Scholar
• Leistikow, I., Mulder, S., Vesseur, J., & Robben, P. (2017). Learning from incidents in healthcare: The journey, not the arrival, matters. BMJ Quality & Safety, 26(3), 252–256. 10.1136/bmjqs-2015-004853
   PubMed Web of Science ®Google Scholar
• Macrae, C. (2014a). Close calls: Managing risk and resilience in airline flight safety. Verlag: Springer.
   Google Scholar
• Macrae, C. (2014b). Early warnings, weak signals and learning from healthcare disasters. BMJ Quality & Safety, 23(6), 440–445. doi:10.1136/bmjqs-2013-002685
   PubMed Web of Science ®Google Scholar
• Macrae, C. (2016). The problem with incident reporting. BMJ Quality & Safety, 25(2), 71–75. 10.1136/bmjqs-2015-004732
   PubMed Web of Science ®Google Scholar
• Macrae, C., & Vincent, C. (2014). Learning from failure: The need for independent safety investigation in healthcare. Journal of the Royal Society of Medicine, 107(11), 439–443. 10.1177/0141076814555939
   PubMed Web of Science ®Google Scholar
• Mann, J., & Currier, D. (2010). Stress, genetics and epigenetic effects on the neurobiology of suicidal behavior and depression. European Psychiatry, 25(5), 268–271.
   PubMed Web of Science ®Google Scholar
• Mann, J. J., Michel, C. A., & Auerbach, R. P. (2021). Improving suicide prevention through evidence-based strategies: A systematic review. American Journal of Psychiatry, 178(7), 611–624. doi:10.1176/appi.ajp.2020.20060864
   PubMed Web of Science ®Google Scholar
• Mills, P. D., Neily, J., Luan, D., Osborne, A., & Howard, K. (2006). Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety, 32(3), 130–141.
   PubMedGoogle Scholar
• Mitchell, I., Schuster, A., Smith, K., Pronovost, P., & Wu, A. (2016). Patient safety incident reporting: A qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’. BMJ Quality & Safety, 25(2), 92–99. 10.1136/bmjqs-2015-004405
   PubMed Web of Science ®Google Scholar
• National Centre for Suicide Research and Prevention. (2022). University of Oslo. Retrieved July 8 from https://www.med.uio.no/klinmed/english/research/centres/nssf/.
   Google Scholar
• National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. (2013). Patient suicide: The impact of service changes. A UK wide study. UK: T. U. o. Manchester.
   Google Scholar
• National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. (2022). NCISH 10 standards for investigating serious incidents. The University of Manchester. Retrieved July 8 from https://sites.manchester.ac.uk/ncish/resources/ncish-10-standards-for-investigating-serious-incidents/.
   Google Scholar
• National Confidential Inquiry into Suicide and Safety in Mental Health. (2022). The University of Manchester,. Retrieved July 8 from. https://sites.manchester.ac.uk/ncish/.
   Google Scholar
• National Institute for Health and Welfare. (2009). National reporting systems for patient safety incidents. A review of the situation in Europe. Helsinki: NIHW.
   Google Scholar
• Neal, L. A., Watson, D., Hicks, T., Porter, M., & Hill, D. (2004). Root cause analysis applied to the investigation of serious untoward incidents in mental health services. Psychiatric Bulletin, 28(3), 75–77. doi:10.1192/pb.28.3.75
   Google Scholar
• Ngwena, J., Hosany, Z., & Sibindi, I. (2017). Suicide: A concept analysis. Journal of Public Health, 25(2), 123–134. doi:10.1007/s10389-016-0768-x
   Web of Science ®Google Scholar
• Nicolini, D., Waring, J., & Mengis, J. (2011a). The challenges of undertaking root cause analysis in health care: A qualitative study. Journal of Health Services Research & Policy, 16(1_suppl), 34–41. doi:10.1258/jhsrp.2010.010092
   PubMedGoogle Scholar
• Nicolini, D., Waring, J., & Mengis, J. (2011b). Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Social Science & Medicine, 73(2), 217–225. 10.1016/j.socscimed.2011.05.010
   PubMed Web of Science ®Google Scholar
• Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30(1), 133–154. 10.1093/epirev/mxn002
   PubMed Web of Science ®Google Scholar
• O’Connor, R. C., & Kirtley, O. J. (2018). The integrated motivational–volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society B, 373(1754), 20170268. doi:10.1098/rstb.2017.0268
   PubMed Web of Science ®Google Scholar
• O'Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal behaviour. The Lancet Psychiatry, 1(1), 73–85. doi:10.1016/S2215-0366(14)70222-6
   PubMed Web of Science ®Google Scholar
• O’Connor, R. C. (2011). Towards an integrated motivational–volitional model of suicidal behaviour. International Handbook of Suicide Prevention, 1, 181–198.
   Google Scholar
• O’Hara, J. K., Reynolds, C., Moore, S., Armitage, G., Sheard, L., Marsh, C., … Lawton, R. (2018). What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study. BMJ Quality & Safety, 27(9), 673–682.
   PubMed Web of Science ®Google Scholar
• Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ Quality & Safety, 26(5), 417–422. doi:10.1136/bmjqs-2016-005511
   PubMed Web of Science ®Google Scholar
• Percarpio, K. B., Watts, B. V., & Weeks, W. B. (2008). The effectiveness of root cause analysis: What does the literature tell us? Joint Commission Journal on Quality and Patient Safety, 34(7), 391–398. doi:10.1016/S1553-7250(08)34049-5
   PubMedGoogle Scholar
• Pham, J. C., Kim, G. R., Natterman, J. P., Cover, R. M., Goeschel, C. A., Wu, A. W., & Pronovost, P. J. (2010). ReCASTing the RCA: An improved model for performing root cause analyses. American Journal of Medical Quality, 25(3), 186–191.
   PubMed Web of Science ®Google Scholar
• Rajendran, S., Mills, P. D., Watts, B. V., & Gunnar, W. (2022). Suicide and suicide attempts on Veterans Affairs medical center outpatient clinic areas, common areas, and hospital grounds. Journal of Patient Safety, 18(1), 33–39. 10.1097/PTS.0000000000000796
   PubMed Web of Science ®Google Scholar
• Roos af Hjelmsäter, E., Ros, A., Gäre, B. A., & Westrin, Å. (2019). Deficiencies in healthcare prior to suicide and actions to deal with them: A retrospective study of investigations after suicide in Swedish healthcare. BMJ Open, 9(12), e032290. 10.1136/bmjopen-2019-032290
   PubMed Web of Science ®Google Scholar
• Rudd, M. D. (2006). Fluid vulnerability theory: A cognitive approach to understanding the process of acute and chronic suicide risk. In Cognition and suicide: Theory, research, and therapy (pp. 355–368). Washington, D.C.: American Psychological Association.
   Google Scholar
• Shojania, K. G., & Thomas, E. J. (2013). Trends in adverse events over time: Why are we not improving? BMJ Quality & Safety, 22(4), 273–277. 10.1136/bmjqs-2013-001935
   PubMed Web of Science ®Google Scholar
• Stene-Larsen, K., & Reneflot, A. (2019). Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scandinavian Journal of Public Health, 47(1), 9–17. doi:10.1177/1403494817746274
   PubMed Web of Science ®Google Scholar
• Trbovich, P., & Shojania, K. G. (2017). Root-cause analysis: Swatting at mosquitoes versus draining the swamp. BMJ Quality & Safety, 26(5), 350–353. 10.1136/bmjqs-2016-006229
   PubMed Web of Science ®Google Scholar
• Turecki, G., & Brent, D. A. (2016). Suicide and suicidal behaviour. The Lancet, 387(10024), 1227–1239. doi:10.1016/S0140-6736(15)00234-2
   PubMed Web of Science ®Google Scholar
• Turecki, G., Brent, D. A., Gunnell, D., O’Connor, R. C., Oquendo, M. A., Pirkis, J., & Stanley, B. H. (2019). Suicide and suicide risk. Nature Reviews Disease Primers, 5(1), 1–22. doi:10.1038/s41572-019-0121-0
   PubMedGoogle Scholar
• van Heeringen, K., & Mann, J. J. (2014). The neurobiology of suicide. The Lancet. Psychiatry, 1(1), 63–72. doi:10.1016/S2215-0366(14)70220-2
   PubMed Web of Science ®Google Scholar
• Van Tilburg, C., Leistikow, I., Rademaker, C., Bierings, M., & Van Dijk, A. (2006). Health care failure mode and effect analysis: A useful proactive risk analysis in a pediatric oncology ward. Quality and Safety in Health Care, 15(1), 58–63. doi:10.1136/qshc.2005.014902
   PubMedGoogle Scholar
• Vincent, C. (2003). Understanding and responding to adverse events. The New England Journal of Medicine, 348(11), 1051–1056. 10.1056/NEJMhpr020760
   PubMed Web of Science ®Google Scholar
• Vincent, C., & Amalberti, R. (2015). Safety in healthcare is a moving target. BMJ Quality & Safety, 24(9), 539–540. 10.1136/bmjqs-2015-004403
   PubMed Web of Science ®Google Scholar
• Vincent, C., & Amalberti, R. (2016). Safer Healthcare: Strategies for the Real World. Cham: Springer. doi:10.1007/978-3-319-25559-0
   Google Scholar
• Vincent, C., Carthey, J., Macrae, C., & Amalberti, R. (2017). Safety analysis over time: Seven major changes to adverse event investigation. Implementation Science, 12(1), 151. 10.1186/s13012-017-0695-4
   PubMedGoogle Scholar
• Vine, R., & Mulder, C. (2013). After an inpatient suicide: The aim and outcome of review mechanisms. Australasian Psychiatry, 21(4), 359–364.
   PubMed Web of Science ®Google Scholar
• Vrklevski, L. P., McKechnie, L., & OʼConnor, N. (2018). The causes of their death appear (unto our shame perpetual): Why root cause analysis is not the best model for error investigation in mental health services. Journal of Patient Safety, 14(1), 41–48. doi:10.1097/PTS.0000000000000169
   PubMed Web of Science ®Google Scholar
• Weissman, J. S., Schneider, E. C., Weingart, S. N., Epstein, A. M., David-Kasdan, J., Feibelmann, S., … Gatsonis, C. (2008). Comparing patient-reported hospital adverse events with medical record review: Do patients know something that hospitals do not? Annals of Internal Medicine, 149(2), 100–108.
   PubMed Web of Science ®Google Scholar
• Wiig, S., Schibevaag, L., Zachrisen, R. T., Hannisdal, E., Anderson, J. E., & Haraldseid-Driftland, C. (2021). Next-of-kin involvement in regulatory investigations of adverse events that caused patient death: A process evaluation (part II: The inspectors’ perspective). Journal of Patient Safety, 17(8), e1707–e1712.
   PubMed Web of Science ®Google Scholar
• Woloshynowych, M., Rogers, S., Taylor-Adams, S., & Vincent, C. (2005). The investigation and analysis of critical incidents and adverse events in healthcare. Health Technology Assessment, 9(19), 1–143, iii. doi:10.3310/hta9190
   PubMed Web of Science ®Google Scholar
• World Health Organization. (2021). Suicide. Retrieved January 13 from https://www.who.int/news-room/fact-sheets/detail/suicide.
   Google Scholar
• World Health Organization. (2022). Patient safety. Retrieved March 23 2022 from https://www.who.int/news-room/fact-sheets/detail/patient-safety.
   Google Scholar
• Wrigstad, J., Bergström, J., & Gustafson, P. (2014). Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: A semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. BMJ Open, 4(5), e005326. doi:10.1136/bmjopen-2014-005326
   PubMed Web of Science ®Google Scholar
• Wu, A. W., Lipshutz, A. K., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. JAMA, 299(6), 685–687. 10.1001/jama.299.6.685
   PubMed Web of Science ®Google Scholar
• Wu, A. W., & Marks, C. M. (2013). Close calls in patient safety: Should we be paying closer attention? Canadian Medical Association Journal = Journal de L'Association Medicale Canadienne, 185(13), 1119–1120.
   PubMed Web of Science ®Google Scholar
• Zimmerman, T. M., & Amori, G. (2007). Including patients in root cause and system failure analysis: Legal and psychological implications. Journal of Healthcare Risk Management, 27(2), 27–34.
   PubMedGoogle Scholar