5 Common Mistakes Organizations Make When Implementing Zero Suicide and How to Avoid Them
Zero Suicide is a comprehensive approach to improving care for individuals who are at risk of suicide within health and behavioral health care systems. Research shows that adopting Zero Suicide is an essential step in preventing suicide in health care settings. As a continuous quality improvement framework, Zero Suicide leverages organizational accountability and data-driven strategies to make suicide care safer.
Implementing Zero Suicide requires more than good intentions—it takes careful planning and a keen eye for potential pitfalls. Following are five common mistakes organizations make when adopting Zero Suicide, along with practical tips on how implementers can successfully avoid or correct these mistakes.
Common Mistakes
1. Not Fully Engaging Leadership and Staff
Mistake: One of the most common mistakes is failing to involve all levels of staff in Zero Suicide implementation. Without buy-in from leadership, the program may lack the necessary resources, commitment, or authority to be successful. Some leaders view Zero Suicide as a stand-alone initiative only and do not integrate its suicide care approaches into existing practices and organizational culture. Likewise, if frontline staff aren’t fully engaged, they may not feel adequately prepared and trained to deliver effective suicide care or to understand the organization’s policies.
How to Avoid It: Ensure there is a clear commitment from the top down. Leaders should champion the initiative and ensure that resources are allocated. Leaders must help staff see and believe that suicide can be prevented and provide tangible supports in a safe and blame-free environment—what is known as just culture. Zero Suicide can be integrated into other initiatives, such as trauma-informed care, accreditation, or CCBHC (Certified Community Behavioral Health Clinics) certification. Similarly, engaging staff at all levels—through training, involving them in planning, and ensuring they understand their role—is crucial for building a culture of collective responsibility.
2. Failing to Use Data Effectively
Mistake: Many organizations start their Zero Suicide journey without clearly understanding their baseline suicide data. Organizations may also fail to collect data to monitor progress and fidelity to care practices over time. Lack of attention to data collection and monitoring can make it difficult to identify problem areas or measure the initiative’s effectiveness.
How to Avoid It: Use data-driven approaches to measure both process and outcome data. For example, you can utilize the Zero Suicide Data Dashboard to identify, collect, and track information. The dashboard gathers data related to implementation, such as suicide screening, assessment, and safety planning along with outcomes such as suicide deaths. These data should be reviewed regularly to identify gaps or areas where the initiative needs improvement. Adjustments should be made to organizational practices to support continuous quality improvement toward safer suicide care.
3. Inadequate Training and Support for Staff
Mistake: While training for the entire health care team is a vital component of Zero Suicide implementation, many organizations mistakenly believe that they can train staff on suicide without addressing the stigma associated with suicide. In addition, a common mistake is having a one-time suicide training, believing that it will cover all aspects of implementing suicide care and organizational policies as well as break down barriers. A lack of ongoing comprehensive training can lead to inconsistent or ineffective care, reducing the effectiveness of Zero Suicide implementation.
How to Avoid It: Provide regular, in-depth suicide-specific training for all staff members, from clinicians to administrative personnel, based on their role. Organizations should train on the tools, policies, and practices that can help staff support individuals who are thinking of suicide. Focus on suicide-specific training with an organizational lens. This training ensures that health care staff have the appropriate tools and support to do life-saving work, including identifying and assessing suicide risk, utilizing collaborative safety planning with lethal means counseling, and establishing meaningful relationships with patients and their families so that they can engage in the treatment. It’s also important to create a system that provides staff with ongoing support and supervision to reinforce their skills and provide feedback.
4. Excluding Voices of Lived Experience
Mistake: Excluding individuals with lived experience—those who have struggled with suicidal thoughts, behaviors, or loss—can be a significant oversight. Their insights are invaluable in understanding the realities of suicide and can provide crucial perspectives on care, communication, and support that can make the Zero Suicide initiative more effective and compassionate.
How to Avoid It: Invite people with lived experience to be involved in the planning, implementation, and evaluation of the Zero Suicide framework. Lived experience might be found among previous or current patients or individuals from your own staff. Include people with lived experience in advisory roles or focus groups or involve them more directly in organizational planning and training sessions. Their voices offer critical guidance on reducing stigma, improving care approaches, and fostering a culture of openness and empathy.
Zero Suicide: Lived Experience
5. Inconsistent screening and assessment practices
Mistake: Inconsistent screening and assessment practices are a major pitfall when implementing Zero Suicide. If screening practices are not consistently utilized or if assessment protocols vary across teams or settings, there may be gaps in identifying individuals at risk of suicide, leading to missed opportunities for intervention.
How to Avoid It: Standardize screening and assessment protocols across the organization. Ensure that every patient is consistently screened for suicide risk at appropriate touchpoints, such as during intakes, annual check-ups, or every visit. Use validated tools for screening and assessment, and ensure that staff are trained to apply them accurately and consistently. Conduct regular electronic medical record audits and feedback loops to help identify inconsistencies and correct them quickly.
Zero Suicide: Identify Element
Conclusion
While Zero Suicide offers a powerful framework for reducing suicide within health and behavioral care systems, success depends on avoiding key mistakes. Organizational commitment, data-driven decision-making, ongoing staff support, inclusion of individuals with lived experience, and standardized screening practices are all critical for achieving meaningful change. Addressing these common pitfalls head-on allows organizations to build a just culture that reduces suicides and ensures every individual receives safer suicide care.
By approaching Zero Suicide with a comprehensive, thoughtful, and inclusive strategy, health care providers can move closer to the aspirational goal of zero suicides.
Laurin Jozlin, Zero Suicide senior project associate, is a licensed clinical social worker with 10 years of experience in suicide prevention, suicide intervention, community mental health, and child and adolescent mental health.
