One-to-one observation not always effective in preventing suicide

The final step in trying to keep a suicidal patient safe is often assigning a “sitter” to the patient.  This practice is often referred to as providing “one-to-one” observation.  While visiting a hospital in Maryland earlier this year, I was privileged to sit in on part of a Grand Rounds presentation by Dr. Jeffrey S. Janofsky, Associate Professor and Director of the Psychiatry and Law Program at Johns Hopkins.  Among the very interesting statistics he presented was one from a study that was published in the Journal of Clinical Psychiatry in  2003* that particularly got my attention. 

This study found:

-28% of patients committing suicide while inpatients had “contracted for safety”

-42% were on 15 minute checks

-20% were on 30 minute checks

-29% were not on regular checks

-9% of inpatient suicides occur while patients are on one-to-one observation.

How can this happen?  His response is that the “sitter” may be distracted, fall asleep, leave the room, be tricked by the patient into leaving him/her alone to go to the bathroom, etc. or the patient may render the “sitter” unconscious.

This information is very surprising to me.  So the question is how do we mitigate this risk?  The only suggestion I can offer is that the rest of the staff on the unit must not rely too heavily on the fact that the at-risk patient has a sitter and assume that no other intervention is needed.  Perhaps creating a policy where patients on one-to-one observation remain on regular 15 minute (or other) rounding checks and that the “sitters” be engaged frequently to see if they need a break or to help them stay alert even if the patient appears to be asleep.

I am curious if others have encountered this situation and if there are other ideas for mitigation.  If so, please comment on this post.

* Busch KA, et all: Clinical correlates of inpatient suicide. J. Clin Psychiatry 2003; 64:14