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Mental Health Environment of Care Checklist

Pen placed on checklist with three boxes checkedThe Mental Health Environment of Care Checklist (XLS, 410KB) (MHEOCC) was developed for Veterans Affairs Hospitals to use to review inpatient mental health units for environmental hazards. The purpose is to identify and abate environmental hazards that could increase the chance of patient suicide or self-harm. The checklist has been used in all VA mental health units since October 2007. Contact for more information.

Learn More

Mills, P.D., Lori A King, L.A., Watts, B V, Hemphill, R. H. (2013). Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards, General Hospital Psychiatry, 35(5),528–536.


One thousand five hundred suicides take place on inpatient psychiatry units in the United States each year, over 70% by hanging. Understanding the methods and the environmental components of inpatient suicide may help to reduce its incidence.

All Root Cause Analysis reports of suicide or suicide attempts in inpatient mental health units in VA hospitals between December 1999 and December 2011 were reviewed. We coded the method of suicide, anchor point and lanyard for cases of hanging, and implement for cutting, and brought together all other reports of inpatient hazards from VA staff for review.

There were 243 reports of suicide attempts and completions: 43.6% (106) were hanging, 22.6% (55) were cutting, 15.6% (38) were strangulation, and 7.8% (19) were overdoses. Doors accounted for 52.2% of the anchor points used for the 22 deaths by hanging; sheets or bedding accounted for 58.5% of the lanyards. In addition, 23.1% of patients used razor blades for cutting.

The most common method of suicide attempts and completions on inpatient mental health units is hanging. It is recommended that common lanyards and anchor points be removed from the environment of care. We provide more information about such hazards and introduce a decision tree to help healthcare providers to determine which hazards to remove.

Watts, B.V., Young-Xu, Y., Mills P.D., DeRosier, J.M., Kemp, J., Shiner, B. & Duncan, W.E. (2012). An Examination of the Effectiveness of a Mental Health Environment of Care Checklist in Reducing Suicide on Inpatient Mental Health Units. Archives of General Psychiatry, 69(6), 588-592.


Suicide is one of the leading causes of death in the United States. While suicides occurring during psychiatric hospitalization represent a very small proportion of the total number of suicides, these events are highly preventable owing to the controlled nature of the environment. Many methods have been proposed, but no interventions have been tested.

To evaluate the effect of identification and abatement of hazards on inpatient suicides in the VHA.

Design, Setting and Patients
The effect of implementation of a checklist (the Mental Health Environment of Care Checklist) and abatement process designed to remove suicide hazards from inpatient mental health units in all VHA hospitals was examined by measuring change in the rate of suicides before and after the intervention.

Implementation of the Mental Health Environment of Care Checklist.

Main Outcome Measure
The number of completed suicides on inpatient mental health units in VHA hospitals.

Implementation of the Mental Health Environment of Care Checklist was associated with a reduction in the rate of completed inpatient suicide in VHA hospitals nationally. This reduction remained present when controlling for number of admissions (2.64 per 100 000 admissions before to 0.87 per 100 000 admissions after implementation; P < .001) and bed days of care (2.08 per 1 million bed days before to 0.79 per 1 million bed days after implementation; P < .001).

Use of the Mental Health Environment of Care Checklist was associated with a substantial reduction in the inpatient suicide rate occurring on VHA mental health units. Use of the checklist in non-VHA hospitals may be warranted.