QPR for Healthcare Professionals
Thank you for your interest in preventing suicide.
An open letter…
Dear Healthcare Professional:
If you are visiting this page, it is likely you have experienced one or more patient suicides in your organization.
A patient suicide is always an “unexpected event” that leads to a “brutal audit” of what went wrong. As a “sentinel event” it may be reported to the Joint Commission, or to some funding source or government agency.
An internal root cause analysis may follow, together with recommendations for change.
A lawsuit may be around the corner.
Question: Will this patient’s death affect the way your organization does business?
Background
Organizational leadership believes the patients they serve are safe and will not die by suicide.
Organizational leadership is often mistaken.
As you know, patient safety concerns are on the rise.
Among “never events” like wrong- site surgery, inpatient suicide is now considered an avoidable adverse outcome. Patient suicide should not happen.
If a patient suicide does happen, it is assumed something may be systemically amiss within the organization.
Organizations that become complacent about patient safety, including suicidal patient safety, are at elevated risk for, not just lawsuits, but external regulatory controls.
A question has been asked by others, “If zero patient suicide is not the goal of your organization, what is the number?”
Developed social policy
In 2001 the National Strategy for Suicide Prevention was published, and in 2002 the Institute of Medicine issued a report entitled, Reducing Suicide: A National Imperative.
Of the key recommendations made in these reports, one was to train healthcare professionals to better detect, assess, manage and treat patients known to be at elevated risk of suicidal behaviors.
With few exceptions, these recommendations have been ignored.
An old saying in medicine states, “You cannot make a diagnosis you don’t know” and, as a result, thousands of suicidal patients go undetected, untreated or undertreated in our healthcare systems.
The life-saving recommendations made by the NSSP and IOM, a decade ago, have yet to be embraced, supported, endorsed or mandated by organizational leadership.
As a result, each day dozens of patients kill themselves while in our care, in our clinics and in our hospitals.
The fact that you are reading these words suggests that, perhaps, your organization may be ready to explore these recommendations and consider a commitment to change.
What we know
Experts agree that together with the provision of a safe treatment environment, competency-based training in the detection, assessment and management of suicidal patients can save lives.
But without institutional leadership, individual practitioners cannot bring about the systemic changes necessary to prevent the “never event” of patient suicide.
Preventing patient suicide is seldom due to the failure of an individual employee, but rather the result of organizational structure and function and, frankly, a lack of “mindfulness” about its operations and how to deal with known and unknown risk.
An invitation to change
We invite organizational leadership to explore patient safety from a different perspective, a perspective known to be effective in error prevention and the successful avoidance of loss of life.
The QPR Institute’s Systems Approach to Suicide Risk Reduction is modeled on the research and recommendations of Karl E. Weick and Kathleen M. Sutcliffe, and their studies of “high reliability organizations” or HROs.
These authors’ studies of nuclear power plants, air traffic controllers, aircraft carriers, hospitals and other high-risk work environments provide essential lessons and tools to help organizations address and improve patient safety practices, policies and protocols.
It is also avoidable.
If you or your organization is interested in exploring how to move from the aftermath of a recent “never event” patient suicide to consideration of adopting our suicide risk reduction training programs, we strongly encourage you to: We are also happy to explore options for the installation of our sustainable “best practice” training programs by telephone conference.
Thank you for your time.
Staff and Faculty, the QPR Institute