Suicide and attempted suicide within inpatient psychiatric units: A 10-year mixed-methods analysis of 143 serious events across 50 facilities (1 September 2026)

Summary

Although suicides and attempted suicides that happen on inpatient psychiatric units present unique challenges to patient safety, most studies in the last 25 years have focused on patient populations outside the United States, which feature different rules, practices, resources, and cultures that may influence their findings. Many of these studies also included incidents that occurred off the unit, such as when patients absconded or shortly after discharge. In contrast, this study draws attention to suicide-related events in the United States, specifically events reported in Pennsylvania from 2016 to 2025 that only occurred on the inpatient psychiatric unit.

This overlooked focus provides fresh insights into the demographics, methods, objects, locations, and temporal patterns involved with on-unit suicide-related events. For example, of the 143 event reports studied, 130 (91%) were attempted suicides and 13 (9%) were suicides, and 57% involved female patients; however, 85% of the completed suicides were by male patients. Neck compression was used in 57% of cases, and suicides by this method frequently involved ligature points. Events typically occurred in private areas, such as bedrooms and bathrooms, and most occurred within the first five days of admission, from October to March, during the evening shift (3 p.m. to 11:59 p.m.). These trends reveal opportunities for further study and strategies to prevent suicide-related events on inpatient psychiatric units.