How on earth, one hates to ask, did a veteran commit suicide while a patient in a Department of Veterans Affairs hospital? Using an item belonging to that patient? When an order had been given for the patient to be watched? When an order had been given for psychiatric care? 

The VA Office of Inspector General noted several things during its investigation afterward: 

First, it found that no one had thought to go through the patient’s things and take away anything that could be a risk for self-harm. Then, staff did not do what’s called a “warm handoff,” which is called for in the suicide risk evaluation guidelines. A psychiatrist apparently did a partial assessment, but didn’t complete it within the required 24-hour time frame so other staff could see it. Instead, the order was changed from constantly watching the patient to checking the patient every 15 minutes. 

The OIG had some recommendations afterward: Reassess the patient before changing observation levels. Actually complete the inpatient notes. Go through the patient’s things and take away anything that could be used for self-harm. And, gosh … what a concept … complete the risk evaluation within the required 24 hours. 

At another facility, the VA OIG concluded that staff inaccurately assessed the suicide risk of three different veterans. 

At yet another, the veteran managed to commit suicide in the emergency room. 

At another VA facility, the OIG stepped in with recommendations after one patient attempted suicide and another was successful. 

Complete the risk screening. Put the notes in the health record. Adhere to one-on-one observation. Don’t deactivate a patient’s high-risk status information without consulting other staff.  

Flipping through years of reports a pattern emerges: There isn’t enough oversight and adhering to rules when it comes to helping suicidal veterans at the VA.  

But of all the missteps small and large, how is it no one thought to clear potentially dangerous items from the veteran’s belongings there in the hospital? 

© 2024 King Features Synd., Inc.