This online RCA toolkit is designed to be a resource for any facility that would like to establish or improve their RCA process. It contains sample policies, position descriptions and agendas, graphic organizers and visual aids, question guides, invitations and ground rules, case studies and other documents that facilities can use to educate their staff, their RCA facilitators, or their leaders about this process.
A multi-source collection of readings, tools, videos, and webinars to help you understand and implement Zero Suicide.
Weiss, A. P. (2009). Quality improvement in healthcare: the six Ps of root-cause analysis. Am J Psychiatry, 166(372).
Jayaram, G., & Triplett, P. (2008). Quality improvement of psychiatric care: challenges of emergency psychiatry. The American journal of psychiatry, 165(10), 1256-1260.
The Joint Commission Root Cause Analysis and Action Plan tool has 24 analysis questions. This framework is intended to provide a template for answering the analysis questions and aid organizing the steps in a root cause analysis.
This report uses New York State Office of Mental Health incident reports to present historical data and a discussion of factors hospitals identified in their root cause analyses that may have contributed to the suicides or areas that otherwise called for improved performance.
Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): an evolving evidence‐based clinical approach to suicidal risk. Suicide and Life-Threatening Behavior, 42(6), 640-653.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., ... Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of general psychiatry, 63(7), 757-766.
Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. Jama, 294(5), 563-570.
This two-page, printable PDF describes the Zero Suicide approach and provides a brief history of the initiative.
These guidelines from Centerstone of Tennessee were developed to aid surviving family members, other clients, and staff in the event a Centerstone client dies by suicide.
These policies and procedures from Centerstone of Tennessee were developed to ensure weapons potentially suicidal and/or homicidal clients wish to relinquish are secured in a safe and appropriate manner.
This letter can be used and adapted to request that staff complete the Zero Suicide Workforce Survey. It should be sent from the chief executive officer, or someone else in a position of leadership, to all staff members.
Oordt, M. S., Jobes, D. A., Fonseca, V. P., & Schmidt, S. M. (2009). Training mental health professionals to assess and manage suicidal behavior: Can provider confidence and practice behaviors be altered?. Suicide and Life Threatening Behavior, 39(1), 21–32.
Schmitz, W. M., Jr, Allen, M. H., Feldman, B. N., Gutin, N. J., Jahn, D. R., Kleespies, P. M., . . . Simpson, S. (2012). Preventing suicide through improved training in suicide risk assessment and care: An American Association of Suicidology Task Force report addressing serious gaps in U.S. mental health training. Suicide and Life Threatening Behavior, 42(3), 292–304.
The New York State Office of Mental Health reviewed suicides occurring within the public mental health system over several years. This report aims to put New York State on a path toward systematically preventing suicide for people in care. It includes details of the review, a summary of findings, and a set of draft recommendations. Appendix 1 lists suicide prevention licensing standards for mental health programs in New York State.
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