November 15, 2019 FAQ – Monitoring Requirements for Suicidal Patients

TJC FAQ191115 

  • Issued November 15, 2019

National Patient Safety Goals (NPSG) (Behavioral Health / Behavioral Health Care)


Suicide Risk Reduction – Monitoring High – Risk Patients


What is the  monitoring requirement for patients at high risk for suicide?


  • In units/areas that contain ligature and/or other safety risks, patients determined to be at high-risk for suicide must be under continuous observation with the ability to immediately intervene through the use of 1:1 observation – 1 qualified staff member to 1 high risk patient.  A qualified staff member is one that has been trained and has demonstrated competence in working wit suicidal patients and performing 1:1 observation.
  • In inpatient psychiatric units/designed psychiatric areas that are ligature resistant and free from other  safety risks, it is up to the organization to determine monitoring requirements for patients determined to be at high-risk for suicide and define such in their policy.