December 2019 DOI:10.33940/behavhealth/2019.12.8
Inpatient Suicide Prevention: A Review of the Patient Safety Authority’s Keys to Ligature Risk Assessment Project
​Author Biographies



Christopher Mamrol, Patient Safety Authority
Christopher Mamrol ( is a senior patient safety liaison with the Patient Safety Authority for the Southeast region of Pennsylvania. Prior to joining the PSA, he worked at Montgomery County Emergency Services, Inc., serving in multiple roles, including as a psychiatric technician, registered nurse, risk manager/patient safety officer, performance improvement director, and Safety and Quality Systems director.

Melanie A. Motts, Patient Safety Authority
Melanie A. Motts is a senior patient safety liaison with the Patient Safety Authority for the Eastern region of Pennsylvania. Previously she worked in outpatient and inpatient settings as a manager, educator, and registered nurse. As director of nursing and a patient safety officer for an acute care hospital in the Lehigh Valley, she led a team of nursing staff, case managers, laboratory staff, and clerical support, which earned the CMS 5-star rating for quality of care provided and patient satisfaction.

Richard Kundravi, Patient Safety Authority
Richard Kundravi is a patient safety liaison with the Patient Safety Authority for the Northwest region of Pennsylvania. Prior to coming to the PSA, he served as the director of Risk Management and Patient Safety at UPMC McKeesport as well as the facility’s corporate compliance officer, privacy officer, director of peer review, and patient representative.


 It takes less than five minutes and 18 inches from the ground for a person to self-asphyxiate from hanging.1 According to the American Foundation for Suicide Prevention (AFSP), suicide is currently the 10th leading cause of death in the United States and 11th in Pennsylvania.2 Of those deaths, hanging from a ligature point is the most common method of suicide in inpatient healthcare facilities. It should be no surprise that the plethora of ligature points in hospitals is a major patient safety concern. For these reasons, the Patient Safety Authority (PSA) launched a project in July 2018 with the aim to assist Pennsylvania facilities in identifying and mitigating ligature risks.

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