Understanding ligature risks in health care facilities


Published March 2021


By Uriah Parker, project sales manager at Allegion


Patients seeking help for mental health or behavioral issues are often vulnerable and in need of a safe place for treatment. It’s important that health care facilities are prepared to care for behavioral health patients’ unique needs. Beyond medical attention, this includes treatment spaces that promote a healthy, restorative environment while limiting opportunities for strangulation and other forms of self-harm.


The health care market, much like the nation, has paid more attention to behavioral health in the last decade. Hospitals have hired patient safety coordinators and facilities have installed hardware that’s designed to prevent injury or self-harm. According to the 2020 Hospital Construction Survey, hospitals are continuing to invest in behavioral health care. Forty (40) percent of respondents with specialty construction projects said they had built or are planning behavioral health care projects. These projects include expansions and renovations because older facilities were not designed to provide the level of patient safety that’s recommended today.


Understanding ligature risks


Hospitals and behavioral health facilities are at high-risk for sentinel suicide events, even when regular monitoring checks are in place. The Joint Commission’s 2018 article “Incidence and Method of Suicide in Hospitals in the United States”, reports that around 75 percent of hospital inpatient suicides were among psychiatric inpatients. Statistics from 2010-2017 show that more than 70 percent of suicide attempts during hospital inpatient treatment utilized a ligature or strangulation point. Almost 54 percent of those used a door or door hardware, commonly in the patient’s bathroom, bedroom or closet.


Given the threat, these types of facilities often have routine monitoring policies in place, especially for high-risk patients. That said, it only takes four to five minutes of adequate pressure on the carotid arteries in a person’s neck to cause death by oxygen deprivation to the brain. Therefore, facilities should mitigate risks by creating safer patient environments, like eliminating ligature points.


Designing for patient safety


Facilities cannot provide constant supervision of every patient—nor would that be a healthy atmosphere for their recovery. The goal of many behavioral health units is to establish a more welcoming environment, avoiding an institutional ambiance. It’s preferred that facilities are designed to “appear comfortable, attractive, relaxing and as residential in character as possible,” per the Behavioral Health Design Guide by Behavioral Health Facility Consulting, LLC. Privacy is not a bad thing; it’s encouraged for healing. However, alone time needs to be considered when planning for patient spaces.


To mitigate suicide risks more effectively, facilities want to create spaces that keep patients safe from self-harm. For example, the US Department of Veterans Affairs (VA) was been able to reduce the number of in-hospital suicides from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions in mental health units. This 82.4 percent reduction was achieved by adopting standards that remove many hazards within the inpatient health units.


The best way to mitigate ligature risks is by being proactive and evaluating each space within the behavioral health unit or facility. It’s not a one-size fits all approach, and it’s crucial to keep in mind conflicting requirements and codes. It’s recommended to conduct a risk assessment for all the different rooms to identify what solutions are needed for each area. The Hunt/Sine Environmental Safety Risk Assessment Matrix (example below) can help determine the level of risk in each location.



Health care risk assessment

Solutions should be chosen for each area based on the intent for self-harm and the amount of privacy. The Behavioral Health Design Guide offers recommendations based on each level, including options for patient units. Because suicide attempts using a ligature point are the most prevalent form of self-harm, it’s especially important to focus on the elimination of attachment points.


Ligature risk assessments and resources


Risk assessments are available online, like this resource from The Center for Health Design.


The Joint Commission published a list of resources to support the implementation of the National Patient Safety Goal (NPSG) 15.01.01, including resources for environmental risk assessments and suicide reduction tools.


Additionally, the “Patient Safety Standards, Materials and Systems Guidelines” recommended by the New York State Office of Mental Health offers guidance on specific products to be used within inpatient psychiatric units.


Allegion behavioral health door hardware


Specifying ligature resistant door hardware can be a life-saving choice for medical facilities. These solutions are designed to reduce the risk of injury or death due to ligature strangulation.


Allegion™ offers a portfolio of behavioral health door hardware that reduces the risk of injury or death due to strangulation. Schlage® recently expanded its lock offering to meet customer needs in low, medium and high-risk applications, as defined by the New York State office of Mental Health. The new HSLR trim features the highest level of ligature resistant design and is available in both mortise and cylindrical chassis. Both ligature resistant trim packages are accepted for high-risk areas by the New York State Office of Mental Health and compliant with Americans with Disabilities Act (ADA) regulations.


Schlage HSLR

  • Available for both the Schlage L Series mortise lock and Schlage ND Series cylindrical lock
  • Recommended for low, medium or high-risk applications
  • The highest level of ligature resistance to positively contribute to healing environments
  • Patented crescent-style handle design
  • “Paperclip Protection” designation as determined by NYS-OMH testing
  • ADA Compliant; “no pinch, no grasp”


Read more about the features.


Applications for ligature resistant hardware

Schlage SL1/SK1

  • Available for the Schlage L Series mortise lock
  • Recommended for low and medium risk applications
  • Multiple safety facets:
    • Recessed trim
    • Sloped surfaces
    • Concealed fastening hardware
  • Integrated clutch that allows the lever to rotate in event of excessive force


Read more about the features.


Zero International ligature resistant gasketing

  • Patented ligature-resistant option prevents unintended usage of the gasketing, including harming oneself or others
  • With ZAG, the rubber is scored before insertion into the aluminum extrusion. This allows for normal function for its specified purpose, but the seal will now break apart if removal is attempted or any weight is placed on the seal.


Read more about the features.