PA PSRS Patient Saf Advis 2007 Sep;4(3):78-82.
Diligence and Design in Behavioral Health Impact Patient Safety
Behavioral Healthcare; Gerontology; Nursing
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Behavioral health facilities are potentially dangerous places for both patients and staff when patients are looking for the opportunity to inflict harm.1 Reports submitted to PA-PSRS indicate that patients continue to harm themselves in behavioral health facilities by using structures and objects common to the behavioral health environment, particularly in patient rooms. Indeed, the majority of patients admitted to behavioral health are at risk for harming themselves or others.2

Although no environment of care can be totally safe and free of risk, facilities can reduce the environmental risk factors that have the potential to cause patient harm by comprehensive planning of facility design.2,3 This article addresses existing guidance for the adult behavioral healthcare unit that is applicable to designing a new building, renovating space, or maintaining an existing behavioral healthcare program. Risk reduction strategies are presented that focus on safe environmental design, staff education, and patient assessment, as well as communication to patients’ families regarding individualized patient care planning, patient safety issues, and community resources.3-5


Since its inception in June 2004, PA-PSRS has received more than 1,900 reports related to behavioral health issues, including suicide, self harm, violent behavior, and possession of items not permitted in the behavioral health environment that may contribute to harm (e.g., illegal drugs, prescription medications, razors, belts, shoelaces). There have been five reported suicides, although others may have been submitted only to the Pennsylvania Department of Health as Infrastructure Failures. Of the five suicides reported to PA-PSRS, four were by strangulation using items such as belts, cords, and clothing. The fifth death resulted from an overdose with contraband medication that the patient had hidden.

Examples of suicides reported to PA-PSRS include the following:

Patient was not in his bed for 7:30 a.m. bed check. Staff attempted to get in bathroom door but couldn't open the door. Staff immediately called security, who pushed open the door. Staff and security witnessed the patient falling behind the door as the belt he used to hang himself was released from the top of the closed door. Patient had no pulse or respirations. Paramedics were called, and patient was deceased.

Patient was admitted with paranoia, anxiety, and agitation. When interviewed by the psychiatrist, he denied suicidal ideation. He was observed in the day hall watching TV with other patients in the evening. Later, a housekeeper entered his room and found him hanging by his shirt on the bathroom door. Staff called a code and began cardiopulmonary resuscitation (CPR) immediately. Resuscitation efforts were unsuccessful, and he was pronounced dead. 

Patient found on floor in bathroom with no respirations and faint pulse. His pants were around his neck as if he tried to strangle himself. Mouth-to-mouth resuscitation was given, and oxygen administration was initiated. 911 was called. The paramedics arrived and initiated CPR. The patient was transferred to the emergency room (ER) and pronounced dead.

The Joint Commission addressed behavioral health patient safety in goal 15 of the 2007 National Patient Safety Goals, which calls on accredited healthcare facilities to identify safety risks inherent in their patient populations (e.g., patient suicide).3 In a review of suicides reported between 1995 and 2002, the Joint Commission identified the physical environment as a root cause in more than 80% of the reported suicides.1 Furthermore, in its November 6, 1998, Sentinel Event Alert, the Joint Commission reported that 75% of patients committed suicide by hanging.6

Elsewhere, patients’ access to potentially dangerous objects may indicate problems with staff competence and training, according to root cause analyses conducted over a 44-month period of 17 attempted and completed patient suicides that occurred in a New York health system.3

PA-PSRS reports further demonstrate the resourcefulness of patients determined to harm themselves despite efforts to the contrary. There have been more than 400 reports of patients harming themselves with objects found in the behavioral health environment. Of these reports, more than 30 were related to attempted suicide by strangulation with common objects such as clothing, belts, bed linens, and shoelaces. About 50% of the more than 400 reports indicated that patients lacerated or punctured themselves with items such as pens, pencils, paper clips, razor blades, and kitchen items, as described in the reports below.

Patient was in kitchen area of group room on unit with doctor. The doctor was called away and left the door open. The patient took a glass dish, smashed it, and began cutting herself on the wrist. She then hid fragments of the glass in her clothing and socks. During lunch, she also hid a fork in her pocket.

Roommate reported that patient had shoelaces around neck. Staff found patient in bathroom with shoelaces around neck. Staff removed [the shoelaces]. Reddened area noted around neck.

Traditionally, behavioral health facilities have focused on access control and surveillance technologies such as fences, locks, key controls, doors and windows, alarm systems, and closed-circuit television systems.1 These strategies may be limited in their ability to address a vital issue to the behavioral health environment—the opportunity for patients to construct weapons from or otherwise harm themselves with objects found in their environment.1

Risk Reduction Strategies

Environmental Design

Because reports submitted to PA-PSRS mainly involve self harm in the patient room, the strategies discussed in this article will focus on this setting. Patient rooms are especially vulnerable areas for patient harm because the extended periods of time that patients spend in their rooms provide ample opportunity for self harm.1,2  Where applicable to the strategies discussed below, relevant cases reported to PA-PSRS are presented. (For further education, PA-PSRS has developed an interactive illustration of the objects or structures in patients’ rooms that have contributed to self harm, according to reports submitted to PA-PSRS.)

Physical structure. Secure and permanently affix walls, ceilings, moldings, and floors to prevent concealment of harmful items such as razor blades, matches, and drugs.1,2 Coat walls, ceilings, and furniture with nontoxic substances in case patients attempt to ingest these materials.1,2 If permitted under fire code, install doors to allow opening in both directions. Recess all hinges, and install doorknobs with push/pull latches and handles pointing down; this installation may reduce the risk of patients using doors (e.g., doorknobs) for hanging.1,2 Recess fire sprinklers and light fixtures, and use tamper-resistant fixtures to prevent their use for hanging. Fasten heating and cooling vents with security screws. Vents with small perforations and protective, fine-mesh coverings are preferable. Place unbreakable covers over lighting and exits signs to reduce patient access to harmful objects.1,2

Attentive design of behavioral health facilities promotes patient safety by denying resourceful patients opportunities to harm themselves. The following PA-PSRS report demonstrates such a resourceful patient:

Patient reported she swallowed metal piece from heating vent in her room. Patient was transported to the ER. Objects were removed by scope.

Windows. Use insulated tempered glass panels at least 1-inch thick for exterior windows.2 Use of sash control devices that limit opening windows to no more than 6 inches may reduce the risk of patients jumping out.3,4 Reinforce older windows with heavy-gauge stainless steel frame and screen fabric. If window treatments are used, use flame-retardant material with no cords.1,2

The report below demonstrates the harm patients may sustain even when windows are reinforced with screening.

Patient was admitted under Section 302 and placed on low level suicide precautions including every 15-minute checks. Patient was found by physician on the deck outside his office having fallen from the window in his room. Patient was transported to trauma center having sustained multiple fractures requiring surgical intervention. The safety screen was bent, and the window was partially broken.

Glass. Use unbreakable glass or acrylic for mirrors and picture frames.1,2  

Patients have managed to harm themselves with both glass and acrylic, as noted in the PA-PSRS reports below.

Patient admitted from the intensive care unit following an overdose. Patient had constant one-on-one visual observation at the time of the event. Patient pushed past staff member and bolted down the hallway. The patient took a picture from the wall and broke the glass (the picture was thought to have been framed with Plexiglass™, as are all of the other pictures on the unit). Patient used a piece of glass to lacerate the left side of her throat, transecting the jugular vein. The code team was called. Pressure was applied to the neck, an intravenous line was started, and oxygen was applied. The patient remained alert and able to speak. The wound was packed with gauze, and the patient was taken to the operating room. The wound was repaired without complications.

Patient punched a picture on the wall, breaking acrylic glass. Patient had lacerations to left wrist that required sutures.

Electrical cords and outlets. Polycarbonate cover plates with tamper-resistant screws provide the best cover for electrical outlets.1,2

The report below indicates patients may tamper with outlet covers and attempt to harm themselves.

Patient called staff to his room and stated, "I tried to kill myself today." He then showed staff that he had partially ripped off an outlet cover and totally removed another. He had used a piece of tinfoil to shock himself. No visible injury was noted.

Electrical cords and any other cords may be used for self harm. Preferably, limit the availability of cords in patient rooms. Secure any cords that must be used and limit the length to less than 12 inches. Cordless phones may be provided for patient use but may not be left unattended in patient rooms because they can be used as weapons.1,2

Phones with cords present the same issues with cords that are discussed above and noted in the PA-PSRS report below.

The patient was found on the floor with a telephone cord wrapped tightly around neck. The patient was cyanotic and breathless. Cord was cut off and patient started to breathe. Patient remained unresponsive and then had a seizure.

Bathrooms. Wall-mounted toilets with plumbing through the back wall will limit patient access to supply piping, which may be used for self harm. Install recessed shower heads, faucets, and spigots. Towel bars, shower curtain rods, and lever handles are not permitted.7 Install breakaway rods and racks for showers, towel bars, and closets to limit opportunities for hanging.1,2

PA-PSRS has received more than 30 reports indicating patients use bathroom appliances to harm themselves, including the following:

While in the bathroom showering, patient attempted to hang self by tying tube socks to pipes under sink. Patient did not respond to medical technician doing 15-minute checks. The patient was immediately untied.

Patient told staff she had swallowed screws that she removed from sink. Patient was transported to the ER, and screws were removed via scope.

Patient turned off water faucet in bathroom hard. It broke off, and it was used to puncture hand between thumb and index finger. Patient was sent to the ED for sutures.

Furniture and miscellaneous items. Sturdy wood furniture bolted to the floor will stand abuse and decrease opportunities to hide contraband. Preferably, any furniture would be difficult to disassemble and have curved instead of sharp edges. A desk chair is the only moveable furniture allowed in the room. If table lamps are used, firmly attaching them to the surface may prevent patients from using the lamp as a weapon. Additionally, avoid using lightbulbs that are not “shatter-resistant.”1,2 Use of paper liners instead of plastic liners in trash cans1,2 may prevent patients from attempting suffocation. Keep medications out of patient rooms, and prevent overdose by only allowing staff to administer.5

For example, the following report of how a patient was injured on room furniture was reported to PA-PSRS:

Patient dismantled dresser in an attempt to barricade self in room. Patient received 2 lacerations on hand from broken dresser drawer, which required 10 stitches.

Performing assessments of the structures most commonly used by patients to self harm and/or attempt suicide may reduce harm to patients. An environmental surveillance tool can be used to document, identify, and eliminate potentially dangerous objects in the environment.3,4 A multidisciplinary team including nursing, quality management, engineering, and staff members certified as healthcare safety professionals may perform the assessment biannually. In addition, facilities may conduct daily walkthrough rounds of rooms, units, and common areas to eliminate potentially dangerous objects.4,5

Staff Education/Training

Education focusing on environmental design and potentially dangerous objects in the behavioral health setting provided to staff may reduce harm to patients.3 Consider the following components for staff education:

  • Educate all clinical staff about the hidden risks of the environment and the behavioral characteristics of the population.3,4,8
  • Educate nonclinical staff, too (e.g., housekeeping, dietary staff). The literature indicates cases in which patients have ingested unsecured cleaning supplies.3 Furthermore, PA-PSRS has received more than 20 reports in which patients have cut themselves with plastic silverware or glass dishes.
  • Conduct annual competencies related to knowledge of potential hazards in the environment.4
  • Provide adequate clinical staff to meet patient needs.3,4,8

Patient Assessment

On admission to the behavioral health facility, performing a patient assessment may help to identify patients at risk for suicide and/or self harm.4 Consider the following components for patient assessment:

  • Revise/implement risk assessment and reassessment tools to identify patients at risk for inflicting harm to themselves or others.3-6
  • On admission and thereafter, conduct an inventory of a patient’s personal items, including clothing.2
  • Perform complete physical examinations on admission to identify contraband, and reassess patients at intervals determined by their individual risk assessment for self harm.5
  • Review and revise as needed the policies and procedures for direct patient observation. The level of observation may vary from constant to random; base observation on individual assessment of the patient.5

Family Education

Educating the families and caregivers of behavioral health patients is an important aspect of care.8 Consider the following components for education:

  • Communicate to families the details of any individualized patient care planning, patient safety issues, and available community resources.3-5
  • Provide family, friends, and visitors with information related to environmental hazards and patient behaviors that may indicate the potential for harm to the patient and/or others.3
  • Advise visitors to have staff review any items brought for patients.3

The behavioral health environment plays a significant, often unrecognized role in patient safety. Achieving balance between designing a risk-free environment while maintaining a therapeutic environment can be challenging, but the mitigation strategies presented here and vigilant attention to the physical environment in behavioral health facilities may reduce patient harm.8


  1. ECRI Institute. Thwarting behavioral health violence through facility design. Healthcare Hazard Management Monitor 2004 Aug;17(12):1-5.
  2. Sine DM, Hunt JM. Design guide for the built environment of behavioral health facilities: second editition—2007 [online]. 2007 Jun 28 [cited 2007 Aug 6]. Available from Internet:
  3. Lieberman DZ, Resnik HL, Holder-Perkins V. Suicide Life Threat Behav 2004 Winter;34(4):448-53.
  4. Dlugacz YD, Restifo A, Scanlon KA, et al. Safety strategies to prevent suicide in multiple health care environments. Jt Comm J Qual Saf 2003 Jun;29(6):267-78.
  5. ECRI Institute. Preventing patient suicides. Risk Management Reporter 2007 Aug;26(4):1, 3-8.
  6. Joint Commission. Inpatient suicides: recommendations for prevention. Sentinel Event Alert 1998 Nov 6 [cited 2007 Aug 6]. Available from Internet:
  7. Guidelines for design and construction of healthcare facilities. Washington (DC): American Institute of Architects; 2006.
  8. Reducing the risk of suicide: using environmental controls to help support suicide prevention efforts. Environ Care News 2006 Oct;9(10):4-5.

Supplemental Material

Behavioral Health Patient Safety Topic

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