Table 1.
Features of reports of suicide-related safety events linked to VA-contracted community care
| Root-cause Analysis % (n) |
Patient Safety Reports % (n) |
|
|---|---|---|
| Total reports | 33 | 55 |
| Facility and Patient Characteristic ^ | ||
| Location of facility | ||
| < 50% of population live in rural area§ | 70.0 (23) | 67.3 (37) |
| ≥ 50% of population live in rural area§ | 30.0 (10) | 32.7 (18) |
| Gender | ||
| Male | 90.9 (30) | 84.0 (46) |
| Female | 3.0 (1) | 7.0 (4) |
| Not reported | 6.1 (2) | 9.0 (5) |
| Event Characteristics | ||
| Event Type | ||
| Confirmed death by suicide | 63.6 (21) | 13.0 (7) |
| Possible death by suicide | 12.1 (4) | 4.0 (2) |
| Confirmed non-fatal suicide attempt | 21.2 (7) | 65.0 (36) |
| Possible non-fatal suicide attempt | 3.0 (1) | 9.0 (5) |
| Other suicidal behavior | 0.0 (0) | 9.0 (5) |
| Method of injury | ||
| Firearm | 36.0 (12) | 15.0 (8) |
| Overdose (e.g., prescription, illicit drugs) | 21.0 (7) | 35.0 (19) |
| Hanging/Strangulation | 18.0 (6) | 13.0 (7) |
| Cutting | 3.0 (1) | 16.0 (9) |
| Other method | 3.0 (1) | 5.0 (3) |
| No method reported | 18.2 (6) | 16.0 (9) |
| Proximity of event to community care treatment | ||
| Inpatient medical-surgical unit | ||
| Event occurred during admission | 3.0 (1) | 1.8 (1) |
| Event occurred ≤ 3 months of discharge | 6.1 (2) | 0.0 (0) |
| Inpatient psychiatric unit | ||
| Event occurred during admission | 3.0 (1) | 0.0 (0) |
| Event occurred ≤ 3 months of discharge | 27.3 (9) | 10.9 (6) |
| Skilled nursing, rehabilitation, assisted living, or nursing home | ||
| Event occurred during admission | 3.0 (1) | 16.4 (9) |
| Event occurred ≤ 3 months of discharge | 3.0 (1) | 0.0 (0) |
| Emergency room | ||
| Event occurred during admission | 0.0 (0) | 1.8 (1) |
| Event occurred ≤ 3 months of discharge | 3.0 (1) | 1.8 (1) |
| Outpatient setting | ||
| Event occurring residential admission | 6.1 (2) | 18.2 (10) |
| Event occurred while receiving outpatient care | 39.4 (13) | 10.9 (6) |
| Other setting | ||
| Event resulted in community hospital admissionǂ | 6.1 (2) | 38.2 (21) |
^
Because the majority of reports were missing information on the age of the patient, we did not report this patient characteristic in the table.
§
Criteria to define rurality are derived from definitions that the Department of Veterans Affairs Office of Rural Health uses to categorize facilities as rural versus not-rural.
ǂ
Patients were typically admitted to the community hospital inpatient psychiatric unit or medical ward for treatment of a recent suicide attempt