Establishment of a Comprehensive Inpatient Suicide Prevention Network by Using Health Care Failure Mode and Effect Analysis.

Inpatient suicide is a common sentinel event. However, evidence supporting effective inpatient suicide prevention measures is currently lacking. In this project, health care failure mode and effect analysis was used in a general hospital quality improvement process to identify suicide risk and reduce inpatient suicide behavior. Interventions were designed to improve steps in the process with the highest risk of failure, resulting in significantly higher consultation rates and reduction of attempted suicide.