Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention

• Published in: Archives of suicide research 2024-01, Vol.28 (1), p.1-19
• Main Authors: Fröding, E., Vincent, C., Andersson-Gäre, B., Westrin, Å., Ros, A.
• Format: Article
• Language: English
• Subjects: Clinical Medicine; Competence; Health care; Humans; Improvement; Interdisciplinary aspects; Intervention; investigation; Klinisk medicin; Learning; Literature reviews; Medical and Health Sciences; Medicin och hälsovetenskap; Multidisciplinary teams; Paradigms; patient harm; Patient safety; Prevention; Prevention programs; Psychiatry; Psykiatri; Safety behaviour; Suicidal behavior; Suicidal Ideation; Suicide; Suicide Prevention; Suicides & suicide attempts; Triage
• ISSN: 1381-1118; 1543-6136; 1543-6136
• DOI: 10.1080/13811118.2022.2133652

The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward. Narrative literature review. Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety. There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift. HIGHLIGHTS There are weaknesses in the current approaches to investigations of suicide. A paradigm shift in investigations is needed to contribute to a better understanding of suicide. New knowledge of suicidal behavior, prevention, and patient safety must be applied.