I AM Patient Safety 2020: Focus on the Patient Award

2020 IAPS Focus on the Patient Award winners, the Ligature Risk Team at Einstein Medical Center Montgomery group photo.

Ligature Risk Team — Kristy Burkart, Kim Tissue, John Barella, Jimmy Hawkins, Mark Menapace, Tom Cleary, and Aurora Capone-Soll

Einstein Medical Center Montgomery


A multidisciplinary team with staff from Quality, Safety, Facilities, Environmental Services, and Nursing took a close look at care for suicidal patients, with a special emphasis on ligature risks in the hospital. Team members walked through the patient care areas and noted every item that could be used as a ligature or anchor point. They were amazed by the number of everyday items that could be dangerous to someone wanting to self-harm.

In addition to the standard process of maintaining 1:1 close observation, the hospital adopted a policy of removing ligature risk items from the suicidal patient's environment unless there was a medical necessity to have the item in the room. Staff was educated on this policy, but the team went a step further: They recreated the same eye-opening experience they had by setting up an activity station outside the cafeteria, at which staff were asked to identify the ligature risks in pictures of patient care rooms and bathrooms. This turned out to be a very powerful activity  that was more immersive than most training exercises.

Alongside the focus on the safety of the physical environment, the Ligature Risk Team identified improvement opportunities in several other steps of caring for suicidal patients. As a result, the hospital now ensures that all personal items are carefully inventoried and secured by Protective Services in a timely fashion to keep the patient, staff, and visitors safe. The team also worked with Dietary Services to increase safety at mealtime by serving finger foods on disposable trays. Staff was re-educated on the safety considerations for performing 1:1 observation of a suicidal patient.

This team working together with an engaged staff throughout the hospital has led to increased safety for a high-risk population.


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