Emergency departments carry the highest suicide-related risk of any non-acute care setting, according to a new analysis from ECRI and the Institute for Safe Medication Practices’ Patient Safety Organization.
The analysis draws on 406 incident reports submitted by PSO members from 2021 through June 2025 and 124 root cause analyses covering 2018 through 2025.
EDs accounted for 73.2% of incidents in the report dataset and 46.8% in the RCA dataset — the highest share among non-acute settings in both.
Patients with chronic mental health conditions or prior behavioral health treatment made up 23.7% of at-risk patients in the root cause analyses, followed by depression (18%), substance use disorder (14.7%) and prior suicide attempts (13.2%). Suicide ideation was the most commonly reported warning sign, appearing in 60.8% of events, while past suicide attempts accounted for 30.3%.
ECRI reviewed 155 corrective action items from the root cause analyses. The most frequent recommendations involved improving communication tools such as handoff protocols and safety huddles (25%), modifying physical environments to remove ligature risks (21%) and strengthening observation practices (15%).
The PSO plans to launch a sprint to help member organizations turn the findings into site-specific improvement plans.
“Patients who are struggling with suicidal thoughts deserve a healthcare system built to notice and respond, not one that leaves front-line teams to catch every warning sign on instinct alone,” Shannon Kooker, vice president of clinical excellence and patient safety at ECRI, said in a July 21 news release. “This analysis is about giving healthcare teams the tools and system-level insight they need to close that gap and protect patients when they are most vulnerable.”
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