A Comprehensive Approach to
Suicide Risk Management in
Behavioral Healthcare
Settings
Paul A. LeBuffe
Devereux
Center for Resilient Children
Suicide & Behavioral Health Providers
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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
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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
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Malpractice
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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
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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
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Component 1 –Train all Staff in Suicide
Prevention
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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:
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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
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Component 2 - Train all Clinicians in
Suicide Risk Assessment
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Utilize the QPR Institute’s QPRT System
Mandated of all clinicians
8 hour training program
Competency based
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Post-test of knowledge
Skill demonstration
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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
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Structured interview format
Essential components
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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
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Component 3 - Formally Assess all
Clients for Suicide Risk
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At admission
At discharge
Prior to leaves/home visits
At significant transitions during treatment
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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
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Procedural document that details staff
responsibilities in the event of a completed
suicide or a life threatening attempt
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Rationale
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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
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Content
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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
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88% expressed one or more positive statements
about the SRRP
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Only 37% expressed one or more concerns
Evaluation Results
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QPR
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QPRT
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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
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Have been very effective in crisis management
But staff must be trained
Evaluation Results - Concerns
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Does not include environmental safety
Training is time consuming – challenges with taking staff
out of ratio for training
Challenges with independent contractors
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Program fidelity and maintenance
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Major risk events monitoring
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Peer review
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Quality site visits
Needs adaptation for individuals with mental retardation
and young children
Outcomes and Benefits
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QPR heightened staff awareness and
increased confidence
QPRT has helped identify clients at risk
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Client with autism
Dispelled myths about individuals with MR
Established standard of care
Crisis response plans improved staff
response
Outcomes and Benefits
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Effects on suicide rate.
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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:
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Paul LeBuffe: plebuffe@Devereux.org
610-542-3090
Devereux Center for Resilient Children
444 Devereux Drive
Villanova, PA 19085