Ligature and Environment Audit



Today’s hospitals and behavioral health facilities must ensure all ligature and self-harm risks are identified and reduced as much as possible

“The organization must consider these risks in patients’ overall suicide/self-harm risk assessments, then implement appropriate interventions to diminish those risks,” The Joint Commission (TJC) points out.

Thre Points Approach to Ligature 

Step 1: Identify. Identify patients who are currently at risk for intentional harm to themselves or others (steps two and three need only be taken with patients who are identified as potential risks).

Step 2: Observe. Provide one-to-one monitoring of at-risk patients with continuous visual observation. The person observing the patient needs to be able to intervene immediately, ASHE points out, noting that video observation is not appropriate since the video monitoring process cannot provide immediate intervention. The organization tells health care organizations to conduct careful reviews of the rules and regulations that apply to their specific facilities.

Step 3: Remove. In any cases where one-to-one continuous observation is not feasible, hospitals must remove or clinically mitigate all environmental risks. Loose items should be removed from the patient area. Fixtures installed in the room do not need to be removed, ASHE states, however, patient access to certain areas may need to be restricted to prevent patients from reaching items that they could use for self-harm.