The complexity of inpatient suicide in a general hospital setting, whether medical or surgical, is not fully understood currently. It is a common sentinel event and an important problem of patient safety. However, its evidence is currently lacking. So, we present a healthcare system approach to enhance the effectiveness of inpatient suicide prevention in Taiwan.

We reviewed available evidence about inpatient suicide. Some risk factors were detected. And we tried to improve our inpatient suicide prevention program with healthcare failure mode and effect analysis (HFMEA), which is a prospective qualitative analysis for numerous medical errors. In this study, HFMEA was used to reduce the likelihood of failure of current clinical practices in preventing inpatient suicide.

The psychiatric consultation rate increased after a series of improvement program. Besides, establishment of an integrated electronic medical system and the improvement of environment and facility safety are our main strategies. The HFMEA indicated that empowering staff with continuing education and case management by a full-time social worker and clinical psychologist were also needed. Furthermore, this hospital-based integrated suicide prevention program was accredited with the symbol of national quality of Taiwan in 2014.

Our study provided systematic intervention to improve inpatient suicide prevention in a general hospital, and in Taiwan. The HFMEA is a useful tool to improve inpatient suicide prevention measures. We still need more information and evidence to promote the importance of inpatient suicide prevention.

The authors have not supplied their declaration of competing interest.