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Ligature Risk from Window Weatherstripping
Patient safety alert

A patient was under frequent observation due to assessed high suicide risk. During one room check, staff saw that the patient had an improvised noose around his neck. The noose was made from window gasket pieces. Because of the frequent room checks and the difficulty in finding ligature tie-off points, this was discovered before the patient could harm himself. After review of the alternatives, benefits and hazards in their specific setting, the hospital replaced window gaskets with tamper-resistant sealants in the locked psychiatry ward’s patient rooms.

Serious ligature harm requires both a ligature and a place to tie it to. In rooms designated for the treatment of psychiatric patients, providing a safe environment includes identifying and eliminating ligature sources and tie-off points.

Sadly, some suicidal patients are very persistent in their efforts to harm themselves. There is always the possibility that a patient will find an unexpected way of hanging him or herself. Thus there is the need to frequently round on high-risk patients as an additional protection against self-harm even in rooms where identified ligature risks have been eliminated.

Information resources

It is important to stay updated on current safe room design resources and monitor sources of new information, such as CHPSO Patient Safety Organization, which disseminates lessons learned from the experience of over 400 organizations, to anticipate and mitigate newly-identified risks before harm ensues.

A common resource for improving suicide safety is the Design Guide for the Built Environment of Behavioral Health Facilities. The guide states: “No built environment—no matter how well designed and constructed—can be relied upon as an absolute preventive measure.” Complicating matters, ligature risk reduction may sometimes need to be balanced against patient dignity and maintaining a healing environment. This is particularly an issue in a patient’s room and bathroom, where complete lack of privacy, while beneficial in reducing ligature risk, could do further harm to the patient’s mental state.

This design guide does not address window weatherstripping. There are other sources of design information that could help supplement it. One such source is New York State’s Office of Mental Health (NYS-OMH) Patient Safety Standards, Materials and System Guidelines. These guidelines are intended for NYS-OMH operated facilities, but the contents, including extensive testing of various manufacturers’ safety devices, can be useful for others.

The New York guide does discuss door gaskets, though not window gaskets. New York discourages the use of anti-ligature gasketing (scored periodically so that it breaks into small pieces when a noose is attempted) as it creates maintenance issues due to ease of vandalism damage. They do recommend tamper-resistant security sealants that are difficult to break apart and ingest, and are poor ligature sources.

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