Report Summary

Title: Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety planning for Patients with Suicidal Behaviors by Firearms
Report Number: 21-00175-19 Download
Issue Date: 11/17/2022
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: National Healthcare Review
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a review of Veterans Health Administration’s lethal means safety (LMS) training, firearms access and safe storage discussions within suicide risk assessments and safety plans, and clinicians’ perspectives on lethal means interventions.

The OIG examined the electronic health records of 480 patients with firearm-related suicide behavior events. Among 15 patients with fatal firearm-related suicide behavior events, who required a comprehensive suicide risk evaluation (CSRE) prior to the event, three lacked required documentation. Six of the remaining 12 failed to assess firearms access and three of six CSREs that documented firearms access failed to include safe storage discussion. Among patients with a non-fatal firearm suicide behavior event, staff failed to include safe storage discussions in approximately 30 percent of CSREs and 21 percent of safety plans.

One-third of Veterans Integrated Service Networks fell below an average of 90 percent compliance with one-time, mandatory LMS training completion. The OIG conducted a national survey of mental health, primary care, and emergency department clinicians. Among respondents who completed LMS training, 75 to 81 percent reported asking most or every patient about firearms access when assessing suicide risk and safety planning. However, only 50 to 56 percent of respondents who did not complete the LMS training reported asking most or every patient about firearms access. The same pattern emerged for safe storage discussions. Additionally, about 60 percent of clinicians who completed LMS training, and about a third of clinicians who did not complete the training, reported documenting firearms access and safe storage discussions.

The OIG made seven recommendations to the Under Secretary for Health related to training compliance and oversight, one-time LMS training, CSRE and safety plan completion, and evaluation of staff barriers to conducting and documenting the suicide risk identification strategy, firearms access, and safe storage discussions.

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