I AM Patient Safety 2019: Focus on the Patient Award

Don Warnick and Peggy (Karish) Leschak
St. Clair Hospital

According to the Centers for Disease Control  and Prevention, one person dies by suicide every four hours in Pennsylvania. The Joint Commission lists suicide as the 10th-leading cause of death in America—a higher mortality than traffic accidents and homicides—and estimates 49–65 inpatient hospital suicides occur annually.

Following a near miss at St. Clair Hospital, a multidisciplinary team consisting of emergency department (ED), behavioral health, information technology (IT), and patient safety leads determined that the central point of failure was related to the unavailability of essential patient history regarding previous self-harm and suicidal attempts. Two months later, Hospital Information System Department members Don Warnick and Peggy (Karish) Leschak had developed an IT solution that searches a patient's electronic medical record (EMR) at registration for a history of self-harm and, if found, alerts the admissions team and clinical caregivers in real time. They also added a triage process to the EMR that uses the Columbia-Suicide Severity Rating Scale (C-SSRS) to identify patients who may require close observation based on how their answers to the questions compare to their history.

Data obtained in the first two months after implementation revealed that 100 patients seen in the ED had a discrepancy between the answers on the C-SSRS and their history of self-harm; these patients were given additional assessments and interventions to ensure their safety. Because the new process has been working so seamlessly in the ED, Don and Peggy also will implement these enhancements throughout the inpatient departments as well.


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