Mac’s Safety Space: Ligature risks and the road ahead

I know we’ve probably discussed this as much as we need to (or perhaps want to), but I want to touch on (hopefully for the last time) what is actually called out in the Federal regulations. I think it could be instructive as one prepares for managing survey findings based on what might best be described as a draconian interpretation of said requirements. Clearly, having one patient harm themselves while they are receiving care and treatment is one too many. But, from a numbers standpoint, the available data does not support a survey strategy of overreach—yet here we’ve been for more than half a decade. Ultimately, the management of the behavioral environment sets the stage for the medical management of the patient—it’s how “ligature-free” became “ligature-resistant”—the world we live in can only be so safe, so we have to promote the appropriate assessment of at-risk patients.

That doesn’t mean there aren’t legit conditions to find (even at this point, go back and look one more time, it’s amazing how much more can be found), but that’s where mitigation comes in. To wit, I give you a passage from page 372 of the State Operations Manual: “(t)he presence of unmitigated ligature risks in a psychiatric hospital or psychiatric unit of a hospital is an immediate jeopardy situation.  Additionally, this also includes any location where patients at risk of suicide are identified. Ligature risk findings must be referred to the health and safety surveyors for further evaluation and possible citation under Patients’ Rights.” Similarly, a memo to State Survey Agency Directors dated July 17, 2023 indicates that “(a)lthough all risks cannot be eliminated, hospitals should be able to demonstrate how they identify patients at risk of self-harm or harm to others and steps they are taking to minimize those risks in accordance with nationally recognized standards and guidelines.”

Appropriately protecting patients from self-harm events (or, truthfully, harm events in general) does not happen by accident but is the result of a great deal of collaboration, communication, and understanding of how these types of risks manifest themselves in the physical environment. Everything and everybody has a role to play in minimizing those risks.

About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at