Table 2.

Root-causes of suicide-related safety events among Veterans who received VA-contracted care in the community

	Root Causes	Descriptive Examples
Variable	N	VA-related factors	Community Care – related factors
Total root causes	129	-	-
Healthcare process related causes (N = 111)
Deficiencies in mental health treatment	34	• No safety plan completed. • No follow-up on community care referral. • No follow-up care arranged after discharge. • Delays in scheduling MH treatment. • Inadequate treatment of comorbid symptoms.	• No safety precautions during inpatient stay. • No follow-up care arranged after discharge. • Abrupt cessation of pain medications. • No medication provided at discharge. • Inadequate treatment of comorbid symptoms
Communication challenges	33	• Failure to relay clinical info to community care providers. • Failure to relay clinical info to other VA staff about a patient hospitalized in community.	• Failure to notify VA staff of care received in the community (e.g., hospitalization). • No response to VA request for clinical info. • Unavailable to participate in PS/QI activities.
Inadequately designed processes of care	21	• No streamlined process to schedule follow-up for patients treated at a community site. • Facilities differ in their approach to gathering clinical information from community sites.	• Indicated MH treatment not available in community in rural location. • Fewer treatment resources available during weekend discharges.
Problems with the suicide risk assessment	11	• Suicide risk assessment not completed. • Contraband search not completed.	• A single report cited problems with suicide risk assessment during community care (i.e., misclassification of a suicide attempt).
Unsafe environment	7	• Two reports mentioned concerns about the safety of VA clinical environment (e.g., access to contraband on VA unit after brief transfer to community hospital for care).	• Access to method to hang self on inpatient psychiatry unit. • Access to method to hang self on medical-surgical floor.
Issues in VA community care office	5	• Delays in completing referral requests. • Community care coordinators not aware of processes for reporting suicidal behavior.	• Lack of a process for non-VA clinic to bill VA properly for pain management. As a result, community care ceases care.
Patient related causes (N = 18)
Low treatment engagement by patient	18	• Patient declines mental health treatment. • Patient no-show appointment.	• Patient requests that community care provider cease all communication with VA providers.

MH = Mental Health; N = Number; PS/QI = Patient Safety/Quality Improvement; VA = Department of Veterans Affairs