ECRI Data Reveals Vulnerabilities in Suicide Risk Management Across Ambulatory Healthcare Settings

New patient safety data analysis can help strengthen suicide prevention protocols in emergency departments and other care settings 

ECRI and the Institute for Safe Medication Practices (ISMP) Patient Safety Organization (PSO) released a Patient Safety Data Snapshot examining suicide-related events in ambulatory healthcare settings. The analysis, drawn from incident reports and root cause analyses (RCAs) from PSO members nationwide, can help inform healthcare facilities’ efforts to prevent and address suicide.

Key Findings

• Care Settings: Emergency departments (ED’s) account for 73.2% of the PSO data on suicide events, underscoring the ED as the highest risk ambulatory environment for suicide-related incidents. The RCA data reflects more care settings, such as behavioral health and home health, but still show ED’s have the highest rates of suicide-related incidents (46.8%).
• Risk Factors: Patients with chronic mental health conditions and current or past behavioral health treatment are most at-risk (23.7% of patients in the RCAs). Other risk factors include depression (18%); substance use disorder (14.7%); and prior suicide attempts (13.2%).
• Warning Signs: Suicide ideation (thinking about or considering suicide) is the most frequently reported behavior (60.8% of events), with suicide attempts comprising 30.3%, reflecting that many cases involve warning signs and opportunities to intervene before harm occurs.

Download the full data snapshot PDF for more information. 

Expert Perspective

“Patients who are struggling with suicidal thoughts deserve a healthcare system built to notice and respond, not one that leaves frontline teams to catch every warning sign on instinct alone. As a nurse, I know how much clinicians want to help and how hard it is when the systems around them aren't designed to support that instinct,” said Shannon Kooker, Vice President of Clinical Excellence and Patient Safety at ECRI. “This analysis is about giving healthcare teams the tools and system-level insight they need to close that gap and protect patients when they are most vulnerable.”

Recommendations for Healthcare Leaders

Root cause analyses (RCAs) document the investigations conducted after safety events, capturing contributing factors and the corrective actions recommended to prevent recurrence. ECRI reviewed 155 corrective action items across these RCAs and identified recurring recommendations.

• Improve communication tools and practices (25% of action items). Recommendations included strengthening change-in-condition alerts, care transition and handoff tools, safety huddles, patient triage protocols, provider-to-patient communication, and post-event debriefings.
• Modify the physical environment (21%). Recommendations included removing ligature-related objects, installing breakaway doors, switching to paper scrubs, and adding security cameras.
• Strengthen observation practices (15%). Recommendations included revising 1:1 observation procedures and patient rounding protocols.
• Revise the discharge process (12%). Recommendations included changes to care management arrangements and direct admissions from outpatient to inpatient care.
• Add or update screening tools (10%). Recommendations included introducing or revising depression, suicide, or agitation screening.
• Revise electronic health record documentation (10%). Recommendations included changes to patient assessment fields, documentation practices, and discharge instructions.

The ECRI and ISMP PSO urges leaders of emergency departments, outpatient clinics, behavioral health programs, and other ambulatory facilities to use this data to assess and strengthen their own practices in several priority areas:

• Communication and care transitions: Communication failures are a recurring problem in the RCAs. Facilities should implement structured handoff tools, direct admission protocols from outpatient to inpatient care when needed, and robust post-discharge follow-up processes, particularly for patients with prior attempts or known behavioral health histories.
• Governance and standardization: Establish systemwide policies with standardized definitions for suicide-related terms and apply continuous quality improvement to close gaps in screening, treatment, and care transitions.
• Workforce readiness: Train clinical and non-clinical staff to recognize warning signs, engage patients with empathy, and escalate concerns without hesitation. Promote psychological safety for staff involved in suicide-related events, who are at risk for secondary trauma.

Safety Sprint Kickstarts Collaborative Learning

ECRI and the ISMP PSO will conduct a patient safety sprint focused on suicide prevention to help member organizations translate site-specific recommendations into action. The collaborative learning program will provide participating teams with tools to identify improvement opportunities, implement evidence-based best practices, and track progress. ECRI patient safety advisors will work alongside participating organizations over several months to support their improvement initiatives.

About the Data Analysis

Ambulatory healthcare settings such as emergency departments, outpatient clinics, and behavioral health programs were included in the analysis. The data snapshot analyzed 406 incidents submitted by PSO member organizations from 2021 through June 2025, plus 124 RCAs about events from 2018 through 2025. Together, these analyses reflect the real-world patient safety experience of healthcare organizations that participate in ECRI and ISMP’s federally certified PSO.

Contact Yvonne Rhodes, Director of Strategic Communications & Operations, YRhodes@ECRI.org 

ECRI is an independent, nonprofit organization improving the safety, quality, and cost-effectiveness of care across all healthcare settings. With a focus on technology evaluation and safety, ECRI is respected and trusted by healthcare leaders and agencies worldwide. Over the past six decades, ECRI has built its reputation on integrity and disciplined rigor, with an unwavering commitment to independence and strict conflict-of-interest rules. ECRI is the only organization worldwide to conduct independent medical device evaluations, with labs located in North America and Asia Pacific. ECRI is designated an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. The ECRI and Institute for Safe Medication Practices PSO is a federally certified Patient Safety Organization (PSO) as designated by the U.S. Department of Health and Human Services. ECRI acquired The Institute for Safe Medication Practices (ISMP) in 2020 to address one of the most prolific causes of preventable harm in healthcare, medication errors; then acquired The Just Culture Company in 2024 to transform healthcare workplace cultures – thus creating one of the largest healthcare quality and safety entities in the world. Visit www.ecri.org.