edi yusuf


Sentinel events can result in death in suicide cases perpetrated by patients with mental disorders. The research was conducted using qualitative method. Themes obtained through coding the results of interviews are first: health workers are less alert, second: the ratio of officers and patients unbalanced, third: not yet implemented SPO patient safety by officers, fourth: facilities and infrastructure of mental hospitals that support the case Sentinel suicide, and depression conditions in patients led to a suicide sentinel case. Prevention strategies for suicide sentinel cases include: preliminary early assessment of suicidal risk patients, improvement of infrastructure facilities that support patient safety, improvement of human resources quality with education and training


Keywords: sentinel, suicide, mental disorders




Sorbello, B. (2008) Responding to a sentinel event. American Nurse Today October 2008 Vol. 3 No. 10. Official Journal of ANA

KPP RS – PERSI. (2008). laporan insiden keselamatan pasien di Indonesia

The Joint Commision International. (2005). Patient safety

The Joint Commision International. (2011). Root Cause Analysis in Health Care:Tools and Techniques. Library of Congress Control Number: 2009931192

Chen, LY, Cheng, TS, & Lin, CH. 2012.Sentinel events and predictors of suicide amonginpatients at psychiatric hospitals. Chenet al. Annals of General Psychiatry2012,11:4 http://www.annals-general-psychiatry.com/content/11/1/4

Keliat, Budi Anna. (2011). Keperawatan Kesehatan Jiwa Komunitas CMHN (Basic Course). Jakarta: EGC.

UU Kesehatan Jiwa Nomer 18 tahun 2014

WHO. (2013). Preventing Suicide: A Global Imperative. Geneva: Switzerland

Nawawi (1997). Metode peneltian di bidang sosial. UGM Press Yogyakarta

Afiyanti, Y., Nur Rachmawati, I. (2014). Metodologi Penelitian Kualitatif Dalam Riset Keperawatan. Jakarta: RajaGrafindo Persada.

Blumenthal, S. (1992). Suicide and gender. American Psychiatric Press, Washington DC

Beaton, S & Forster, P. (2012). Insights into men’ s suicide. InPsych | The bulletin of The Australian Psychological Society Limited

Stuart, G.W. (2013). Principles and Practice of Psychiatric Nursing. St.Louis Missouri: Mosby

Townsend, CM. (2009). Psychiatric mental health nursing Concept of care in evidence base practice. (6th Ed.). Philadelphia: F.A. Davis Company.

Varcarolis & Halter. (2012). Psychiatric nursing clinical guide; assesment tools and diagnosis . Philadelphia : W.B Saunders Co

WHO. (2009). Human Factors in Patient Safety Review of Topics and Tools. © World Health Organization (WHO), 2009 WHO/IER/PSP/2009.05

Zaki, Rania A. (2016). Job Stress and Self- Efficacy among Psychiatric Nursing Working in Mental Health Hospitals at Cairo, Egypt. Journal of Education and Practice ISSN 2222-1735 (Paper) ISSN 2222-288X (Online) Vol.7, No.20, 2016

Carayon, P & Gurses, A. (2008). Chapter 30. Nursing Workload and Patient Safety—A Human Factors Engineering Perspective. https://www.ncbi.nlm.nih.gov/books/NBK2657/pdf/Bookshelf_NBK2657.pdf

Oyebode, F. (2006). Clinical errors and medical negligence. Advances in Psychiatric Treatment (2006), vol. 12, 221–227

Smith, P & Millar, M. (2011). The Quiet Room: Improving the Acute Care Psychiatric Environment. https://www.fons.org/Resource/ Documents/Project%20Reports/PFWhytemansBraeDec12.pdf

Oquendo MA, Currier D, Mann JJ. Prospective studies of suicidal behavior in major depressive and bipolar disorders: what is the evidence for predictive risk factors?. Acta Psychiatr Scand 2006: 114: 151–158 All rights reserved DOI: 10.1111/j.1600-0447.2006.00829.x

Schafer, et al. (2008). Correlates of Suicidality Among Patientswith Psychotic Depression. Suicide and Life-Threatening Behavior 38(4) August 2008 2008 The American Association of Suicidology

Bagley, S. Chapter 26. Identifying Patients at Risk for Suicide: Brief Review (NEW). Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety ractices.https://www.ncbi.nlm.nih.gov/books/NBK133374/

McBroom, S. (2012). Reducing Inpatient Suicide RiskIn The Hospital Setting. Compass. Vol. 12, Issue 3

Janofsky, J. (2009).Reducing Inpatient Suicide Risk:Using Human Factors Analysis to Improve Observation Practices. J Am Acad Psychiatry Law 37:15–24, 2009


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