Document Detail

Systemic Vulnerabilities to Suicide among Veterans from the Iraq and Afghanistan Conflicts: Review of Case Reports from a National Veterans Affairs Database.
MedLine Citation:
PMID:  21309821     Owner:  NLM     Status:  Publisher    
While suicide among recently returned veterans is of great concern, it is a relatively rare occurrence within individual hospitals and clinics. Root cause analysis (RCA) generates a detailed case report that can be used to identify system-based vulnerabilities following an adverse event. Review of a national database of RCA reports may identify common vulnerabilities and assist in the development of more robust prevention strategies. Our objective was to identify and compare common themes among reports of suicide among veterans of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) in the Veterans Affairs system. Common themes among root causes of suicide as identified in RCA reports were collected and compared as the primary outcome-systematic vulnerabilities. Actions recommended within the reports were coded as the secondary outcome-prevention strategies. Fifty-one RCA reports of OIF/OEF suicides were identified by our search. Coding generated 16 common categories among 132 root causes, and 13 categories among 108 recommended actions. Assessment of suicidal risk, coordination of care, timely access to care, and communication among providers were the most common root causes. Actions identified by RCA teams to reduce suicide included improving referral processes, staff education in suicide assessment, and follow-up with suicidal veterans. Review of multiple RCA reports can identify organizational vulnerabilities detected at the local level that may be applicable system wide. Attention to improving suicide assessment, coordination of care, and timely access may have the largest impact on reducing suicide among OIF/OEF veterans.
Peter D Mills; Samuel J Huber; Bradley Vince Watts; James P Bagian
Publication Detail:
Journal Detail:
Title:  Suicide & life-threatening behavior     Volume:  41     ISSN:  1943-278X     ISO Abbreviation:  -     Publication Date:  2011 Feb 
Date Detail:
Created Date:  2011-2-11     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  7608054     Medline TA:  Suicide Life Threat Behav     Country:  -    
Other Details:
Languages:  ENG     Pagination:  21-32     Citation Subset:  -    
Copyright Information:
© 2011 The American Association of Suicidology.
Peter D. Mills, VA National Center for Patient Safety Field Office, White River Junction, VT, and Department of Psychiatry, Dartmouth Medical School, Hanover, NH, USA; Samuel J. Huber, VA National Quality Scholars Program, White River Junction VA Medical Center, White River Junction, VT, USA; B. Vince Watts, VA Patient Safety Fellowship, White River Junction VA Medical Center, and Department of Psychiatry, Dartmouth Medical School, Hanover, NH, USA; James P. Bagian, Professor, Medical School and College of Engineering, University of Michigan, and Founding Director, VA National Center for Patient Safety, Ann Arbor, MI, USA.
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