Joint Commission – Anti-Safety in Action


Severe pain can trigger suicide in hospital ERs” the headline reads. If they’re still calling it an “ER” you already know they’re clueless.

The article at the National Library of Medicine cites a new “Sentinel Event Alert” from the Joint Commission (.pdf download) urging emergency departments to be on the lookout for patients who may commit suicide in the Emergency Department.

Since 1995, there have been 827 reports of patient suicides in the United States. Of those, about 14% are in non-behavioral health units, making a total of about 116 non-psychiatric inpatient suicides in 15 years.  That’s about 8 inpatient suicides per year out of 198 million inpatient days per year (644 inpatient days per 1000 population in US x 307 million US population) for a total chance of an inpatient committing suicide on any given day of … 1 in 24.75 million.  Now I admit that the numbers may be off by one in a couple million or so because reporting suicides is voluntary for hospitals, so not all suicides get reported.

The Joint Commission also breaks down the number of suicides reported in the emergency department since 2005 — 8% of 827 reports or about 66 patients. In 15 years in all the emergency department in the country, 66 people killed themselves. That adds up to about 4 patients per year. Let’s round up to 5 patients per year who kill themselves in emergency departments. During that same time period, the number of emergency department visits per year averaged 100 million. Latest statistics show that we’re up to about 117 million emergency department patient visits per year. So the number of suicides committed per patient visit in the emergency department is about … 1 in 25 million – give or take a few million.

Now the Joint Commission’s “Sentinel Event Alert” wants hospitals to take a bunch of additional affirmative steps to make sure that even less than 1 in 25 million patients commits suicide.

Hospital staff is more likely to buy a winning lottery ticket than they are to find an inpatient who will commit suicide on any given day. Yet not only are hospital staff required to keep a close look-out for suicidal patients, but they and/or the hospitals will be held responsible for a “never event” if an inpatient actually does commit suicide.

You want an example of how people expect medicine in the United States to be “perfect”? Here it is.

I’m sure that all of the JCAHO minions are furiously typing out a counterargument that “WhiteCoat is a cold heartless person. He doesn’t care about trying to save people who might commit suicide.” Yeah, well cool your keyboards. Maybe we can ask a patient if they’re depressed or suicidal. Give them a number to follow up with a counselor. I might agree to that.

But JCAHO and our government have a page and a half long list of “recommendations” that medical providers are supposed to follow in order to prevent suicide – include “doing suicide screenings in the ER, screening all patients for depression when they’re admitted to a hospital, checking anyone deemed to be at risk for items they could use to harm themselves, and encouraging staff to call a mental health professional to evaluate patients believed to be at risk.” I uploaded the alert to EP Monthly’s site here in case JCAHO decides to take it down or the link goes dead.

Let’s say that we implement all of JCAHO’s recommendations – just in the emergency department. Not only do we need to perform all the screening, we also need to DOCUMENT that we perform all the screening because when the clipboard brigade comes knocking for an audit, you better be able to prove that you actually did the screening that they “recommend.” Conservatively, let’s say that such screening and documentation takes 10 minutes. Multiply that by 117 million patient visits. If every emergency department in the country implements JCAHO’s recommendations, emergency department staff will spend an extra 2o million hours each year looking for a needle that is in a haystack the size of Texas (which just happens to have a population of 25 million).

Those screening and documentation procedures add up to 20 million hours less patient care. That’s 20 million hours that won’t be available to treat patients waiting in the waiting rooms. Twenty million less hours to dispense medications, discharge patients, and monitor critically ill patients. More than 100 million extra pieces of paper to document adherence. And those numbers don’t even count all the extra time spent doing additional screening and documentation when the patient make it to the medical floors.

What’s the cost to the system? If we assume that emergency department nurses make $35/hour, those 20 million hours add up to $700 million per year … to screen for a problem that occurs 5 times per year. Then add in the cost of the paper and of all the supervisors who then have to go through the charts to make sure that the documentation is present (and properly completed) and the time cost throughout the country easily surpasses $1 billion. Well, if only half the hospitals in the US implement the recommendations, the cost is only a measly $500 million.

These safety recommendations were created by the government’s Patient Safety Advisory Group, a group that was chaired by an astronaut named James Bagian and co-chaired by a pharmacist named Michael Cohen. Now you have another example of what happens when non-clinicians create policy for those of us in clinical practice.

But at least patients are safer …. right?


  1. Just out of curiosity, how are you supposed to screen patients who are delivered to the ED intoxicated, unconscious, or incoherent?

    • “both and MD and Engineer”

      An MD who never even finished his residency. And sitting through a 4.5 hour seminar to be eligible for “flight surgeon” status doesn’t impress me, either.
      Going to medical school and doing half an anesthesia residency thirty years ago doesn’t tell you a heck of a lot about the clinical practice of medicine in 2010.
      I’m not qualified to make recommendations about aerospace safety just because I look through a telescope and ride on commercial airliners every year. He isn’t qualified to make medical safety recommendations based on his history. End of story.

  2. That wouldn’t at all be like the US Government outlawing drop-side cribs because there have been a whopping 32 confirmed deaths due to improperly installed drop-sides in the last 10 years. That’s 3.2 kids per year. More kids die from vaccine reactions, circumcisions, heck – choking on hot dogs or falling down stairs in any given year than die due to a drop-crib!

    Next you know, hot dogs and all non-ranch style homes will be illegal, too. We all know vaccinations and circumcision never will be.

  3. About the still calling it an ER thing….

    I wish it would go away and the ED thing catch on, or for people to call us EP docs.

    It doesn’t sound like it is ever going away though. I think the verbiage is goin to stick. Probably bc of the tv show

    • If you tell people you are an ‘ED nurse’ or an ‘ED doctor’, you’re just going to have poor, unsuspecting people picturing you try to give erections to your patients, whether you want to keep that image out of everyone’s heads or not.

      Call me a lust for colloquial English, but I would rather be associated with the show ER, not floppy penises.

      • That’s why we call ourselves emergency physicians and emergency nurses. Like the “Emergency Nurses Association” and “American College of Emergency Physicians”.
        No Viagra needed.

  4. The problem is that proposed regulations should be run past a significant sample of those who would have to follow the regulations. And a majority of those people should have to agree that the regulation is needed “beyond reasonable doubt.”
    Unfortunately, that ain’t never going to happen because the regulators will never give up their power.

    And as far as ER vs. ED. Patients are never going to say they’re coming to the ED. So give up fighting it. The work is the same and the pay is the same whether it’s called a room, a department or an area!

    • Might as well call it was it is-
      “24 hour Medicaid, nursing home clinic, chronic pain clinic and social services center”

  5. These rules will, at 10 minutes per patient, add up to a cost of 2,852 years of patients’ lives per year. If we divide that by the potential 5 patients per year, who might be saved if they respond positively to TJC ideas, that would be 570 years spent for each potentially prevented suicide.

    This also raises a question. Should any positive response to any TJC ideas have its own DSM-V diagnosis?

    For those who are not upset by the 570 patient years spent trying to save, and probably failing to save one suicide, remember that each of those screenings includes a nurse, too.

    Not just 570 patient years per potential life saved, but 570 nursing years. A total of 1,140 years spent on this imaginary ability to prevent suicide by a TJC screening exam.

    Where is the evidence that this intervention is in any way successful?

    Where is the evidence that this intervention does not encourage patients to commit suicide at higher rates than if they did not have the screening?

    Where is the evidence that this intervention does not encourage nurses to commit suicide?

    With a lifespan of about 80 years, this is 9 full patient lives – birth through to death at 82 years old – for each potential suicide saved and 9 full nurse lives – birth through to death at 82 years old – for each potential suicide saved.

    This isn’t at the level of Osama bin Laden or Timothy McVeigh, but it has potential. Especially if this encourages suicide. It’s TJC. Give them time to build up to their full serial killer potential. Don’t rush them.

    • Oopsy. I am tired. My numbers are off.

      440 patient years per potential suicide prevented.

      Ditto for nurse years.

      5 1/2 patient lives each year and 5 1/2 nurse lives each year. Not just dead, but non-stop torture with these screenings. No sleep. No food breaks. No let up at all. That kind of 80 years times 5 1/2 patients plus 80 years times 5 1/2 nurses.

    • Silly Rogue – still trying to use a scientifically valid methodology. Everyone knows that numerical analysis should only be used in historical context.

      The new method is Qualitative Research. It has given such epic JC singsongs as “never events” and my personal favorite… the “pain” scale.

      Why, I just found out the other day, according to a nursing prof, that if you have true pain you cannot become addicted to narcotics and the prof has the qualitative data to prove it. And Fibromyalgia.

      It pains me some to lose the old reliable quantitative methodology, but at least I won’t be addicted to narcotics.

      • igloodoc,

        I have no problem with the pain scale, but the 0-10 pain rating is not the only way to assess pain. We do a horrible job of addressing pain, but that does not mean that a TJC solution is going to make things better.

        Not becoming addicted only applies if we distort our definition of addiction. Addiction is initially seeking a high, rather than relief from pain. Dependence is seeking only relief from pain. There is a psychological difference. The patient with dependence is supposed to be much more likely to want to decrease their dose, when their pain medicine is more than adequate for the pain. They are not looking for the feeling of being high and might not even like it.

        Nothing about that prevents the patient from becoming addicted. Fortunately, the research shows that pain patients do not seem to become addicts at any higher rate than the general population.

        When it comes to drugs and addiction, people lose their ability to think rationally. Our drug laws probably do more to encourage drug use, than to discourage drug use. Our drug laws create an environment that helps organized (and disorganized) crime to thrive. Our drug laws encourage corruption and disrespect for law and disrespect for the police.

        We lie to our children about the dangers of drugs, but they will see first hand that these scare stories are lies. Then our children wonder why we need to lie to them and wonder if we tell them the truth about anything at all. Our drug laws create an environment that glorifies drug abuse.

        If we want to create drug seekers, all we need to do is inadequately treat pain. Patients in pain will seek drugs to treat pain. We will not improve outcomes by under-treating pain. It should not be a choice between making the pain tolerable to the patient vs. narcosis.

        We worry about the wrong things, because we do not understand risk management. TJC is full of formulaic unicorn solutions to real world problems. TJC cannot differentiate among the different real world problems, when attempting to improve things. Stopping suicide is good, but it is counterproductive to attempt to do this by endangering all patients, increasing the already bloated costs of medical treatment, distracting nurses from patient care, and increasing staffing shortages.

      • Wow. Pain scale to to bad laws to organized crime to lying to children. Yup. It’s because we aren’t prescribing enough narcotics. The patients in the three local rehabs here might disagree.

  6. EM doc from the Jerse on

    From MMWR: “During this 7-year span, 84 national parks reported 286 suicide events, an average of 41 events per year. Of the 286 events, 68% were fatal.” Suicides in National Parks – United States, 2003-2009 December 3, 2010 / 59(47);1546-1549.

    I guess the National Parks System needs to implement a policy checking all visitors for depression and suicidal ideation/thoughts. About 285 million people visit a National Park each year. And the two parks (Blue Ridge Parkway in North Carolina and Virginia and the Golden Gate National Recreation Area in California) with the most visitors had the most suicides (ha! statistics is funny that way). Imagine if the Federal Government had to do this paperwork instead of us…which my ED has been for 4 years and the RNs (especially at triage) hate it, even though it “just check boxes.”

    • Not my usual ID on

      It is not just visitors at the National Parks (even though, my brother-in-law’s brother jumped off the Golden Gate Bridge, and lived), that might be at risk for suicide; What about the extremely highly stressed out employees who work at the parks?

      Working for a concessionaire, even more so than working for the National Park Service, leads to suicidal ideation. Lots of responsibility, but very little to no authority to carry out the job requirements; plus living in cramped employee dormatories or tent cabins, with no choice of roommates is extremely stressful.

      Also, just because someone has suicidal ideation, does NOT mean that they will act on it immediately; a suicide can take months, years, or even decades of planning, searching for just the right method.

  7. Huh. I wonder if that’s where my nursing instructor got her freak out from. I did a dressing change, left the scissors etc. in the room for the next nurse and my instructor just freaked out. “You can’t leave anything sharp in a patient’s room.”
    “Uhhh, what?”
    “They might hurt themselves with it.”
    “He’s not a psych patient. I mean. He’s here for a diabetic foot ulcer.”
    “Still, you never know!”
    “But it took us like fifteen minutes to round up all the supplies for his dressing change the first time around…”

    • I’d be more worried about the patient hurting nurses with the scissors. assaults on hospital staff are way too common and hospitals often refuse to prosecute/discourage staff from prosecuting.

  8. I find the whole concept of a “never” event to be so laughably ludicrous that things like this no longer shock me, just make me shake my head.

  9. Has anyone ever tried to see if there is a correlation between escalating prescription drug abuse and mandating pain control and the”pain is a fifth vital sign”?
    Methinks there might be.

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  11. WhiteCoat, I’ve thought for a long time now that the Joint Commission was more an organization making money and justifying it’s own existence than actually improving patient safety. This is a great example ….

  12. Joanne Peterson on

    I can not speak to the value of the screening. I don’t know enough about it at this point.
    I do know that the sentinel event advisory group is not in the business of wasting time on inconsequential issues. Drs Bagian and Cohen (Veterans Affairs and Institute for Safe Medication Practices respectively), carry out their work by going to gemba, the place where the work is done. That is the bedside practitioner.

  13. take it a step further…multiply the estimated amount of time spent surveying prospective suicide cases by the average pay of the person who may be tasked to complete the survey.

    Ex: 20 million hours x Minimum wage of $7.75 = more than most would care to spend.

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  15. So this issue was covered recently in ACEP news and we were discussing it in the ED when it was slow on a night shift…and something dawned on me…what about the whopping 86 percent of in-hospital suicides that occur on behavioral health units…wouldn’t that be a much better target for interventions statistically?

    But even then- if behavioral suicides are 6 times more likely that an ED suicide (86/14 = 6) then that is still a problem that happens in 1 in every 4 million patients!…(yes, I know that the math is screwy on that and I just compounded error but I’m an EM resident, not a statistician)

    But I guess I forgot that this is all about nitpicking wherever nitpicking can be done no matter what the cost or lack or reason attached to it…

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