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Readings
Coffey, M. J., Coffey, C. E., & Ahmedani, B. K. (2015). Suicide in a Health Maintenance Organization Population. JAMA psychiatry.
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Tools
The Zero Suicide Work Plan Template should be used by an implementation team after completing the Zero Suicide Organizational Self-Study. It is organized by the various elements included as part of the comprehensive Zero Suicide framework.
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Readings
Weiss, A. P. (2009). Quality improvement in healthcare: the six Ps of root-cause analysis. Am J Psychiatry, 166(372).
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Readings
Jayaram, G., & Triplett, P. (2008). Quality improvement of psychiatric care: challenges of emergency psychiatry. The American journal of psychiatry, 165(10), 1256-1260.
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Tools
This online RCA toolkit is designed to be a resource for any facility that would like to establish or improve their RCA process.
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Tools
The Joint Commission Root Cause Analysis and Action Plan tool has 24 analysis questions. This framework is intended to provide a template for answering the analysis questions and aid organizing the steps in a root cause analysis.
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Readings
This report uses New York State Office of Mental Health incident reports to present historical data and a discussion of factors hospitals identified in their root cause analyses that may have contributed to the suicides or areas that otherwise called for improved performance.