Suicide risk: asking the question, sizing the risk, setting the precaution
A five-rung vertical ladder read top to bottom, each rung a bar whose width grows with risk, with assessment findings at left and the matching observation level and environmental action at right.
SCREEN EVERY PATIENT — screening with a validated instrument is required for patients being evaluated or treated for behavioral health conditions in any setting. Screening is a nursing action, not a referral, and a positive screen triggers an immediate risk assessment rather than a consult order and a wait.
ASK DIRECTLY — the question is asked in plain words: "Are you thinking about killing yourself?" Asking does not plant the idea and does not raise risk. Vague phrasing produces vague answers, so "you're not thinking of doing anything silly, are you" is a wrong option every time it appears. Then ask what the plan is, what method, whether the method is available, and when.
SIZE THE RISK — four determinants carry the most weight: a specific plan, the lethality of the method, access to the means, and how soon. Layer on prior attempt, recent loss, hopelessness, substance use, giving away possessions, and command hallucinations telling the patient to harm himself. Weigh protective factors such as children at home or a religious prohibition, but never let a protective factor cancel a plan with access.
THE FALSE CALM — sudden brightening after prolonged depression can mean the decision has been made and the ambivalence is over. Energy returns before mood. Increase observation; do not relax it.
MATCH THE PRECAUTION — continuous one-to-one observation within arm's length for high or acute risk, including during toileting and showering. Timed checks at irregular intervals for lower risk, never on a predictable schedule the patient can time. The provider order names the level; the level is re-evaluated at least every shift and whenever the picture changes.
MAKE THE ENVIRONMENT SAFE — remove belts, shoelaces, cords, drawstrings, scarves, glass, mirrors, sharps, plastic bags, lighters, and all personal medication. Inspect belongings with the patient present so the search is transparent rather than punitive. Ligature-resistant fixtures in the room and the bathroom. Count and account for utensils after every meal.
WHAT DOES NOT WORK — a written no-suicide contract is not evidence-based and never substitutes for observation. Neither does a verbal promise obtained in conversation. A safety plan the patient helps build, listing warning signs, coping steps, and people to call, is a different tool and is appropriate.
Memory hook: PLAN — Plan · Lethality · Access · Now.
Watch outsudden calm is not improvement. Margin note: ask it out loud, in those words. Facility policy governs observation intervals. → BOOK 03 for who may be assigned to observe. → BOOK 12 · P10 for postpartum screening.
Takeawaya specific plan plus available means plus a near timeframe means continuous observation now, and the environment is searched before the conversation continues.