Psychiatric hospitals carry inherent safety concerns due to high-acuity conditions such as suicide risk. In high-risk environments like psychiatric hospitals, it is critical to maintain a safe environment of care, situational awareness, robust training, and consistent monitoring. A key aspect of safety is an environmental risk assessment that not only categorizes areas that could be used to attempt suicide, but also results in a mitigation plan to address areas of ligature risk. Organizations should routinely evaluate their environments for ligature risks per policy. Conducting a risk assessment annually at minimum is a recommended best practice, although changes in the environment such as physical renovation(s) should prompt the organization to conduct a reassessment.
An effective mitigation plan provides clear guidance on the feature that poses risk, rationale of concern, assessment, and guidance. Examples of guidance include recommended cord lengths and avoidance of bed sheets with elastic banding. Mitigation strategies involve removal of hooks and bars that serve as anchor points. But what can be done if a ligature risk cannot be removed or immediately modified? For example, a ligature resistant door handle may be on back-order, or an open handrail is required per Americans with Disabilities Act (ADA) standards. In these situations, it is imperative that staff are trained on mitigation strategies, such as increased monitoring, while the risk is being addressed. Leaders play a critical role in expediting ligature mitigation efforts including oversight and obtainment of ligature resistant items. At a site visit, we observed how a leadership team incorporated follow-up to a mitigation strategy through their leadership rounds. As leaders rounded, they asked staff about the ligature risk with the corresponding mitigation strategy to verify proper monitoring as described in the environmental risk assessment. Examples such as this demonstrate how staff training and leadership oversight can successfully manage ligature risks.
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