In the article Inpatient Suicide and Suicide Attempts in Veterans Affairs Hospitals The Joint Commission conducts a landmark study that reveals the root causes of inpatient suicide.  This is a particularly important study because it reviews all reported inpatient suicide or suicide attempts within a large national health care system.

Suicide is the eleventh leading cause of death in the United States. Approximately 1,500 suicides occur in inpatient hospital units in the United States each year… Doors and wardrobe cabinets accounted for 41% of the anchor points when hanging was the method of selfharm… Careful review of RCA reports of inpatient suicide has resulted in focused interventions to improve patient care and patient safety in VA medical centers….

Sadly, they find that “veterans are twice as likely as nonveterans to die of suicide,” which makes suicide prevention in VA medical centers a particular challenge.  Each VA hospital now has a patient safety manager who investigating the “adverse events” that occur at that facility.  Of these adverse events, suicide by hanging over a door or door hardware  with bedding was found to be the most frequent.   The study reports that a “reduction of environmental hazards become critical to suicidal behaviors.”