Table 3.

Key findings in patient safety reports of suicide-related safety events among Veterans who received VA-contracted care in the community

		Descriptive Examples
Variable	N	VA-related factors	Community Care – related factors
Identified Problems (N = 64)
Unsafe environment	21	• A single report mentioned concerns about the safety of VA clinical environment (i.e., access to medications in urgent care clinic).	• Access to cord from call light in ED bathroom. • Access to O2 tubing on nursing home floor.
Deficiencies in mental health treatment	17	•No follow-up care arranged after discharge from community care hospital. • No safety plan completed. • No safety precautions during ED stay.	• No follow-up care after patient reported suicidal statements during outpatient visit. • No follow-up care arranged after discharge. • No safety precautions during inpatient stay.
Communication challenges	13	• Failure to relay clinical info to other VA staff about a patient treated in community. • Failure to relay clinical info to community care providers during patient transfer.	• Failure to notify VA that a patient was hospitalized for treatment of a suicide attempt. • VA staff unable to reach community care providers to coordinate clinical care.
Problems with the suicide risk assessment	7	• Suicide risk assessment not completed.	• Suicide risk assessment not completed
Other problems	6	• Patient declines MH treatment and admission to VA hospital for treatment. • Billing incident results in community care provider cancelling MH treatment.	• Limited information on event because no RCA available from community care site. • Prior to event, there were issues with the ED suicide risk protocol at the site.

ED = Emergency Department; MH = Mental Health; N = Number; RCA = Root-cause Analysis; VA = Department of Veterans Affairs