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US Patent # RE42,991 & RE44,039 September 2018 
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This Month's Article 

What is a Sentinel Event?

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What is a Sentinel Event? 

The Joint Commission defines sentinel events as occurrences to patients in medical facilities “…involving death or serious physical or psychological injury, or the risk thereof." As you will note from the pie chart above, patient suicides are a comparatively frequent sentinel event identified by The Joint Commission. The Door SwitchTM was developed to mitigate the most common method of suicide employed in medical facilities—hanging using a door as a ligature point.

Please visit The Joint Commission for more information on sentinel events.

About Us 

The Door SwitchTM is the original top-of-the door ligature attempt warning system and holds U.S. Patents RE 42,991 and RE 44,039. We have been serving mental health professionals since 2006.

Each Door SwitchTM is a pressure sensor activated by approximately one to two pounds of downward pressure applied to the top, rather than the face (front or back surfaces), of the door. With system activation at the top of the door, ligature devices applied from either side of the door result in system alerts. Hospital staff are notified of system alerts by a combination of audible alarms, strobes, and door identification provided at a keypad typically located at a nurses’ station. The system utilizes proven Honeywell electronic components, including the Honeywell Vista 128BPT panel as the controller.

The Honeywell Vista 128BPT control panel provides an event log that records the times and dates of 512 events. The controller records the application of pressure to one of the system’s Door SwitchesTM, the removal of that pressure, and the turning of a key switch to silence the alarm. Logged events can be viewed from the keypad or downloaded to a computer and printed.

The Door SwitchTM has been installed in mental health facilities across the country. We are proud to state that we have many satisfied mental health facility clients and can provide you with their contact information for reference purposes.

For additional information, a demonstration of The Door SwitchTM, or a free quote, please call or email us.  

The Joint Commission Gives Suicide Prevention Tips

Over the past five years, an average of 85 suicides have been reported as sentinet events to the Joint Commission. In an effort to come to a consensus on mitigation strategies, the Joint Commission brought together officials from provider organizations, suicide prevention experts, behavioral health designers, Joint Commission surveyors and staff, and members of the Centers for Medicare & Medicaid Services (CMS) to discuss these strategies. 

A guidance of eight recommendations for inpatient units addressing only the most contentious issues was developed.

Below are these recommendations: 

1. IPUs must be “ligature-resistant” in patient rooms, patient bathrooms, corridors and common patient areas. The panel defined ligature-resistant as areas, “Without points where a cord, rope, bedsheets, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or suicide.”
2. The doors in IPUs located between patient rooms and hallways must contain ligature-resistant hardware including hinges, handles and locking mechanisms.
3. Hospitals should not be required to have risk mitigation devices installed in IPUs that decrease the chances the top of a corridor door will be used as a ligature attachment point.
4. In IPUs, the transition zone between patient rooms and patient bathrooms must be ligature-free or ligature-resistant.
5. IPU patient rooms and bathrooms must have a solid ceiling (a drop ceiling is not an acceptable alternative).
6. In IPUs, drop ceilings can be used in hallways and common patient care areas as long as all aspects of the hallways are fully visible to staff and there are no objects that patients could easily use to climb up to the drop ceiling, remove a panel, and gain access to ligature risk points.
7. In IPUs, medical needs and the patients’ risk for suicide should be carefully assessed and balanced to determine the optimal type of patient bed to meet both medical and psychiatric needs. If patients require medical beds with ligature points, appropriate mitigation plans and patient safety precautions must be in place.
8. Standard toilet seats with a hinged seat and lid are not a significant risk for suicide attempts or self-harm; they should not be cited during surveys and do not need to be noted on a risk assessment.

To read the full report  click here.  

The Door Switch wants to continue the fight for more awareness and provide additional resources to dispel the myths about mental health issues and solutions for safety issues. We also continue to strive to provide a product that keeps the hospital environment safe. We continue to be committed to better practices and procedures in mental health community. For information concerning our safety product, please click here


The Door SwitchTM  



The Door SwitchTM 
11772 Westline Industrial Drive
St. Louis MO 63146

(877) 998-5625 toll free

US Patent No. RE42,991 and RE44,039

 US Patent No. RE42,991 & RE44,039                                                                                    

11772 Westline Industrial Drive
Saint Louis, MO 63146
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