A Comprehensive Approach to
Suicide Risk Management in
Behavioral Healthcare
Settings
Paul A. LeBuffe
Devereux
Center for Resilient Children
Suicide & Behavioral Health Providers
Suicidal ideation/behavior is the most
common reason for adult psychiatric
admissions
15-20% of completers die while in
treatment
Of inpatient suicides, 1/3 occur in hospital,
1/3 on pass, 1/3 on AWOL status
High incidence of suicide at admission,
near discharge and within the first 3
months post-discharge
Comprise 13% of sentinel events reviewed
Consequences of Patient Suicide
Worst possible outcome for the patient
Tragedy for family
Increased risk for family, other patients & staff
Suicide clusters
25% of psychologists; 50% of psychiatrists lose
a patient to suicide
Possible career or agency ending event
Possible malpractice exposure
Negative public relations
Malpractice
Suicide malpractice is the #1 cause of suits
against all mental health practitioners
Few graduate programs in behavioral
health disciplines provide explicit training in
suicide assessment & management
Duty to protect ensure that resources are
used for treatment
Type III error
Goals of Suicide Risk Reduction Program
(SRRP)
Reduce the incidence of patient suicides & lifethreatening attempts
Manage suicidal crises in a way that reduces the
risk of a suicide cluster
Protect agency against unnecessary lawsuits
In the event of a suicide - provide assurance to
staff that they exceeded the community standard
of care
Four Components of a SRRP
Train all staff in suicide prevention
Train all clinicians in suicide risk assessment
Assess all clients for suicide risk
Develop suicide-specific crisis response
plans for each program
Component 1 –Train all Staff in Suicide
Prevention
Gatekeeper training model
Endorsed by the Surgeon General
Train all staff
Selected the Question, Persuade, Refer (QPR) Program
Subject of an NIMH-funded randomized clinical trial
Recognized by Joint Commission as a best practice
Received the Negley Award
Developed by Paul Quinnett, QPR Institute, Spokane,
WA
Component 1 –Train all Staff in Suicide
Prevention
60 to 90-minute training
Designed to:
raise awareness
dispel myths & misconceptions
teach warning signs
teach 3 skills to avert suicide
Goal is to have staff escort client to clinician
for evaluation
Component 1 - Evaluation Results
Many accompanied referrals
Most, but not all of the time, clinicians knew of
elevated risk
Clinicians appreciate additional information
Clinicians report that it sensitizes staff
100% of Devereux centers recommended
continuing QPR training
Component 2 - Train all Clinicians in
Suicide Risk Assessment
Utilize the QPR Institute’s QPRT System
Mandated of all clinicians
8 hour training program
Competency based
Post-test of knowledge
Skill demonstration
In the classroom (role plays)
In vivo
% Passed
100
90
80
70
60
50
40
30
20
10
0
All
Other
Interns
Nurses
Therapists
Psychiatrists
Social Workers
Psychologists
Results: Component 2 (Cumulative)
Pre-test
Post-test
Component 2 – The QPRT
Structured interview format
Essential components
Assess suicidal thoughts and plans
Assess risk and protective factors
Assess willingness to commit to a safety plan
Outcome – assign a risk level with associated
treatment intents
Justify decision
Consult
Document
Component 2- Evaluation Results
General Satisfaction – 43% “very valuable”
Advantages
Systematic approach – useful especially with
new clinicians
Provides good documentation
Requires justification for risk & monitoring
However, needed revisions and adaptations to
Devereux populations and programs
100% recommended continuing with revised
QPRT
Component 3 - Formally Assess all
Clients for Suicide Risk
At admission
At discharge
Prior to leaves/home visits
At significant transitions during treatment
change in risk factors/protective factors
change in placement/caregivers
Documented in core clinical record
QPRT Flow Chart
Y
QPRT-P
Are 1 or more of the 3
indicators present? 1
Can client participate in a structured interview?
Review history, interview caregivers regarding suicide,
etc.
Y
AGE
Y
N
Age <10?
AgeAges
10-18?
10-18
Age > 18?
Y
Y
Chart level of suicide risk2
and treat as indicated
QPRT-P
QPRT
Chart specific function, and
level of suicide risk2 and
treat as indicated
Y
Y
Are there selfinjurious behaviors
present?
Conduct FBASpecific function
hypothesized/identified?
N
Default is to treat behavior
as suicidal. Chart level of
suicide risk2 and treat as
indicated
N
Chart level of suicide risk2
and treat as indicated
N
Malpractice
Issues and Errors
Type 1 Error:
Failure to detect risk.
Type 2 Error:
Substandard care or treatment
Type 3 Error:
Postvention failure
Component 4 - Crisis Response
Plans
Procedural document that details staff
responsibilities in the event of a completed
suicide or a life threatening attempt
Rationale
Importance of an “affectively calm” environment
Reduce risk of suicide clusters
Help staff, clients and families cope
Avoid unnecessary litigation
Component 4 - Crisis Response
Plans
Content
First responder duties
Safety of clients
Needs of unit
Needs of staff
Needs of families
Reporting and documentation requirements
Management of outside contacts
QI and periodic review
Staff must be trained!
Evaluation Results
Feedback
88% expressed one or more positive statements
about the SRRP
Only 37% expressed one or more concerns
Evaluation Results
QPR
QPRT
Clinicians welcome staff monitoring patients
High compliance rates
Established an attainable, universal “basal level” of
suicide risk assessment
Quality and completeness must be monitored
Needed significant modifications (now available from
QPR Institute)
Crisis response plans
Have been very effective in crisis management
But staff must be trained
Evaluation Results - Concerns
Does not include environmental safety
Training is time consuming – challenges with taking staff
out of ratio for training
Challenges with independent contractors
Program fidelity and maintenance
Major risk events monitoring
Peer review
Quality site visits
Needs adaptation for individuals with mental retardation
and young children
Outcomes and Benefits
QPR heightened staff awareness and
increased confidence
QPRT has helped identify clients at risk
Client with autism
Dispelled myths about individuals with MR
Established standard of care
Crisis response plans improved staff
response
Outcomes and Benefits
Effects on suicide rate.
Had a low base rate to begin with
Significant reduction in completed suicides
Significant reduction in life-threatening attempts
Helped avert at least 5 staff suicides
To Reach Me:
Paul LeBuffe: plebuffe@Devereux.org
610-542-3090
Devereux Center for Resilient Children
444 Devereux Drive
Villanova, PA 19085
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