Suicide Screening and Ligature Risk Assessment Bundle



Together, these resource tools support a safe environment for all patients from two distinct perspectives: evaluation and mitigation of individual risk of self-harm and evaluation and mitigation of environmental risk conditions.

Ligature Risk Assessment Resources

This collection of detailed tools supports surveillance of inpatient units to identify and manage potential ligature risk points within the department that could put a patient at risk for harm to self. Each tool is designed to support compliance with ACHC standards for accreditation but can be further customized to align with the hospital’s policies and procedures.

Separate assessments for behavioral health and non-behavioral health units are based on the differing expectations for a safe environment. For behavioral health units, the goal is ligature-resistance. For non-behavioral health, the goal is staff awareness and proactive mitigation where ligature risk is identified. For these units, a shift-based bedside checklist is an additional resource.

The tools:

  • Ligature Risk Assessment – Behavioral Health Unit(s)
    • Risk and Corrective Action Dashboard
    • Unit-based Compliance Assessment
  • Ligature Risk Assessment – Non-behavioral Health Unit(s)
    • Risk and Mitigation Dashboard
    • Unit-based Risk Assessment
    • Environmental Mitigation Checklist – Non-behavioral Health Unit(s)

Suicide Screening and Assessment Resources

Hospitals are expected to screen all patients for suicide risk. This collection of detailed tools helps establish screening, assessment, and interventions to support effective care in a safe environment.

The tools:

  • Overview and template use instructions
  • Template Policy – Suicide Screening, Assessment, and Interventions in Non-behavioral Health Settings
  • Suicide Risk Screening and Assessment Quality Improvement Tool
    • QAPI Dashboard
    • Monthly Audit Form
    • Screening Compliance Audit
    • Intervention compliance Audit
    • Corrective Action Documentation
    • Environmental Mitigation Checklist – Non-behavioral Health Unit(s)
    • Environmental Mitigation Checklist – Non-behavioral Health Unit(s)
  • Suicide Risk Mitigation – Non-behavioral Health Unit Shift Checklist

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