Abstract
This study examines a near-miss suicide by a high-risk military patient in an acute psychiatric ward. Using Root Cause Analysis (RCA), latent errors in system design and communication were identified, guiding strategies to enhance patient safety and care quality.
Objective: The purpose of this study was to implement RCA in a military suicide event and improve the process of care in an acute psychiatric ward.
Methods: The RCA process involves identifying the problem, establishing a timeline, identifying the causes, creating a cause-and-effect diagram, and implementing strategies. We conducted personnel interviews and on-site walk to understand the operations and environment, reconstructing the caring process. Discussion meeting was held to examine error points, and a fishbone diagram was developed to systematically analyzed latent threats. Improvement strategies were formulated based on personnel, time, place, factors, and setting. In order to implement improvements, we included the implemented measures into regular standard monitor.
Results: Following classification of the incident as Class B (High Risk), why-tree analysis identified the root causes as "incomplete organizational system design" and "ineffective information delivery." Accordingly, short-term goals included re-examining the environment and eliminating risk factors; medium-term goals, encompassed improving history-taking processes for new patients and accelerating information delivery among family, military units, and healthcare professionals; long-term goals focused on promoting patient safety awareness among staff and ensuring continuous monitoring.
Discussion: This military suicide highlights a systemic flaw in healthcare environment. RCA analysis revealed that routine care processes require continuous improvement and evaluation. In this case, overlooked potential factors existed in everything from patient integrity assessment and the completeness and efficiency of information delivery to the generally perceived "safe" environment in acute psychiatric ward. Patient safety needs to shift from "building barriers to reduce errors" to "systematically predicting potential patient safety events." Only through integrated reflection and reconstruction can build a resilient healthcare system, and implementing the core of patient-centered care.
Notes
References:
Karkhanis, A. J., & Thompson, J. M. (2021). Improving the Effectiveness of Root
Cause Analysis in Hospitals. Hospital Topics, 99(1), 1–14. https://doi-
org.mhdla.flysheet.com.tw:8443/10.1080/00185868.2020.1824137
Mabunda, N. F. (2024). Nurses’ perceptions of involving family members in the care of mental health care users. Curationis, 47(1), 1–9. https://doiorg.mhdla.flysheet.com.tw:8443/10.4102/curationis.v47i1.2538
Wahlstedt, E., Levy, B. E., Scott, E., Stephens, W., Fletcher, K. E., & Harris, A. (2025). Implementation of a Standardized Tool for Root Cause Analysis Selection. Journal of Patient Safety, 21(2), 101–105. https://doi-org.mhdla.flysheet.com.tw:8443/10.1097/PTS.0000000000001291
Watson, B. M., & Wu, X. I. (2023). Sentinel Events and Miscommunication What do we know in 2021: A Language and Social Psychology Framework. Health Communication, 38(9), 1770–1779.
Sigma Membership
Lambda Beta at-Large
Type
Poster
Format Type
Text-based Document
Study Design/Type
Other
Research Approach
Other
Keywords:
Acute Care, Advancing Clinical Care, Suicide Risk Factors, Suicide Prevention, Military Personnel, Psychotherapy Patients
Recommended Citation
Lin, Li-Ling; Li, Kai-Wen; and Lin, Yun-Shih, "Preventing the Next Tragedy: Applying Root Cause Analysis (RCA) in a Military Suicide Event" (2026). International Nursing Research Congress (INRC). 64.
https://www.sigmarepository.org/inrc/2026/posters_2026/64
Conference Name
37th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Toronto, Ontario, Canada
Conference Year
2026
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2026-08-06
Preventing the Next Tragedy: Applying Root Cause Analysis (RCA) in a Military Suicide Event
Toronto, Ontario, Canada
This study examines a near-miss suicide by a high-risk military patient in an acute psychiatric ward. Using Root Cause Analysis (RCA), latent errors in system design and communication were identified, guiding strategies to enhance patient safety and care quality.
Objective: The purpose of this study was to implement RCA in a military suicide event and improve the process of care in an acute psychiatric ward.
Methods: The RCA process involves identifying the problem, establishing a timeline, identifying the causes, creating a cause-and-effect diagram, and implementing strategies. We conducted personnel interviews and on-site walk to understand the operations and environment, reconstructing the caring process. Discussion meeting was held to examine error points, and a fishbone diagram was developed to systematically analyzed latent threats. Improvement strategies were formulated based on personnel, time, place, factors, and setting. In order to implement improvements, we included the implemented measures into regular standard monitor.
Results: Following classification of the incident as Class B (High Risk), why-tree analysis identified the root causes as "incomplete organizational system design" and "ineffective information delivery." Accordingly, short-term goals included re-examining the environment and eliminating risk factors; medium-term goals, encompassed improving history-taking processes for new patients and accelerating information delivery among family, military units, and healthcare professionals; long-term goals focused on promoting patient safety awareness among staff and ensuring continuous monitoring.
Discussion: This military suicide highlights a systemic flaw in healthcare environment. RCA analysis revealed that routine care processes require continuous improvement and evaluation. In this case, overlooked potential factors existed in everything from patient integrity assessment and the completeness and efficiency of information delivery to the generally perceived "safe" environment in acute psychiatric ward. Patient safety needs to shift from "building barriers to reduce errors" to "systematically predicting potential patient safety events." Only through integrated reflection and reconstruction can build a resilient healthcare system, and implementing the core of patient-centered care.
Description
This article applied the Root Cause Analysis (RCA) to uncover latent system flaws in design and communication in a near-miss military suicide case. Aims to Learn practical short-, medium-, and long-term strategies to shift from reactive barriers to proactive, resilient, patient-centered safety systems.