A Review of Modifiable Health Care Factors Contributing to Inpatient Suicide: An Analysis of Coroners' Reports Using the Human Factors Analysis and Classification System for Healthcare.

Background: Inpatient suicides have devastating and long-lasting consequences for patients, families, and health care organizations, posing a major challenge for hospitals. Although many studies have identified patient risk factors for inpatient suicide, the modifiable health care factors are less understood. Failure to understand these modifiable factors weakens organizations' ability to design and implement effective prevention strategies.

Methods: The Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare) was used to classify and analyze modifiable health care factors that contributed directly or indirectly to inpatient suicides in Australian hospitals between 2009 and 2018. Comparisons were made between general and psychiatric hospital units to identify context-specific recommendations.

Results: Of the 367 cases, 216 (58.9%) had enough information to analyze the contributing factors, and 214 (58.3%) included unit location information. Multiple modifiable health care factors were identified in the cases as contributing to the patients' suicides. Commonly, cases reported decision errors made by individuals (57.4%), problems with the physical environment (56.0%), and unit-level operational decision-making errors (that is, planned inappropriate operations) (48.6%). An association was found between unit type and problems with coordination, mental state, tasks, physical environment, planned inappropriate operations, and organizational culture (p < 0.05).

Conclusion: General prevention initiatives may not be effective in addressing inpatient suicides across specialty units. HFACS-Healthcare enabled a deeper understanding of inpatient suicide and the identification of priority areas that, if addressed, could help reduce the number of preventable suicides in hospitals. Hospital suicide prevention initiatives need to be tailored to specific units and target individual and system vulnerabilities to improve safety and reduce inpatient suicide rates.