Updated October 2025

Practice-ready Guide

Suicide Risk Assessment and Safety Planning in Clinical Care

Clinicians should shift from sole risk prediction toward collaborative, patient-centered assessment, formulation, and safety planning. Use brief validated screens to identify risk, perform focused therapeutic assessment, address acute/proximal and distal risks, restrict lethal means, and create a written Safety Planning Intervention with rapid follow-up. Implementation science supports system-level adoption and sustainability.

Clinical question

How should clinicians perform suicide risk assessment and implement safety planning to reduce near-term risk in routine clinical settings?

Suicide PreventionRisk AssessmentSafety PlanningEmergency PsychiatryPrimary CareImplementation Science

Key points

Screen universally, assess therapeutically

Use brief tools to flag risk, then engage in collaborative, formulation-based assessment to inform management rather than rely on risk scores alone ^[2], ^[7].

Build a written, personalized Safety Plan

Co-create a stepwise Safety Planning Intervention with warning signs, internal coping, social/professional supports, and lethal means restriction steps, and schedule rapid follow-up ^[5], ^[6].

Target proximal drivers

Address acute stressors, intoxication, agitation, command hallucinations, and access to means; treat modifiable risks promptly while documenting protective factors ^[2], ^[10].

Close the follow-up gap

Transitions of care are high risk; active outreach and early post-visit contact are key implementation targets and improve outcomes ^[11], ^[13].

Make it stick at the system level

Use implementation strategies (workflow redesign, audit-feedback, training) to sustain universal screening and safety planning across settings ^[11].

Evidence highlights

From prediction to therapeutic assessment and risk management ^[2]

Clinical pivot

Greater patient–clinician collaboration reduces suicidal ideation (RCT) ^[3]

Collaboration impact

CDC’s 7 strategies guide multi-level prevention ^[5], ^[6]

System strategies

Clinical Workflow

Stepwise Suicide Risk Assessment and Safety Planning

A concise, repeatable pathway emphasizing collaboration, formulation, and rapid risk mitigation.

1) Universal/targeted screening

Use brief validated screens (e.g., in EDs, pediatrics, and primary care) to detect risk efficiently; screen-positive patients require structured assessment ^[7], ^[11].

2) Therapeutic assessment and formulation

Shift from prediction to a collaborative, narrative assessment that identifies proximal (current intent, plan, access, agitation, substance use) and distal (history, diagnoses, trauma) factors, protective factors, and mechanisms linking them ^[2], ^[10].

3) Determine immediacy and level of care

If active intent, plan, access, or impaired judgment is present, initiate emergency precautions (constant observation, means restriction, possible hospitalization). If no imminent risk, proceed with enhanced outpatient care and close follow-up ^[2].

4) Safety Planning Intervention (SPI)

Co-create a written plan: warning signs; internal coping; social distractions; supportive contacts; crisis lines; professional/urgent care; means restriction steps. Provide copies (patient, EHR, caregivers as appropriate) ^[5], ^[6].

5) Treat modifiable risks

Manage acute psychiatric symptoms, pain, insomnia, substance use; optimize evidence-based treatments; address social determinants (housing, violence, financial stress) ^[5], ^[6], ^[10].

6) Rapid follow-up and caring contacts

Arrange follow-up within 24–72 hours after acute visits; use phone/text/portal caring contacts and active outreach; prioritize transitions of care ^[11], ^[13].

7) Documentation and communication

Document risk formulation, rationale for disposition, safety plan elements, and consultation; communicate with care team and, when appropriate, family/caregivers ^[2], ^[11].

8) Implementation and quality improvement

Embed screening and SPI in workflows; train staff; use audit/feedback and champions; monitor fidelity and outcomes to sustain gains ^[11], ^[13].

Point-of-Care

Assessment Elements, Risk Factors, and Safety Planning

Use these checklists during encounters and at care transitions.

High-immediacy red flags

Current suicidal intent, plan, or rehearsal; recent attempt ^[2]

Access to lethal means (firearms, medications) ^[5], ^[6]

Intoxication, severe agitation, command hallucinations ^[2], ^[10]

Marked hopelessness, panic, or escalating distress ^[2]

Recent discharge from psychiatric/ED or care transition ^[11], ^[13]

Proximal and distal risks

Proximal: acute stressor/loss, intoxication/withdrawal, psychosis, severe depression/anxiety, pain, insomnia ^[2], ^[10]

Distal: prior attempts, mental disorders, trauma/ACE, chronic pain, family history, social isolation ^[9], ^[10]

Pediatric settings: screen-identified risk in ED/medical patients is detectable with brief tools ^[7]

Therapeutic assessment prompts

“What has changed recently that makes this harder?” (formulation focus) ^[2]

Explore intent, capability, reasons for living, ambivalence ^[2]

Elicit patient goals; collaborate to enhance autonomy and alliance ^[3]

Safety Planning Intervention (SPI) essentials

List personal warning signs and early cues ^[5], ^[6]

Identify internal coping strategies before contacting others ^[5], ^[6]

People/places for distraction; supportive persons to disclose crisis

Professional/urgent resources; crisis lines; local ED access ^[5], ^[6]

Specific steps to restrict/remove lethal means (firearm off-site storage, lockboxes, medication blistering) ^[5], ^[6]

Follow-up and engagement

Schedule contact within 24–72 hours; warm handoffs at discharge ^[11], ^[13]

Caring contacts (brief, non-demanding messages) between visits ^[11]

Troubleshoot barriers: transport, costs, childcare, telehealth options ^[11]

Implementation pearls

Standardize screening triage rules; EHR prompts; order sets ^[11]

Train multidisciplinary teams; gatekeeper education sustains competence ^[11]

Use PDSA cycles; audit/feedback; identify champions; track fidelity and outcomes ^[11], ^[13]

Evidence Signals

What the Evidence Emphasizes

Key takeaways with level of support.

Assessment approach

Strong: Shift from prediction to therapeutic assessment and risk management; categorical risk scores alone are insufficient for clinical decisions ^[2].

Collaboration with patients

Emerging RCT evidence: enhanced patient–clinician collaboration during risk assessment reduces suicidal ideation (directionally beneficial) ^[3].

Screening utility

Moderate: Brief screening tools identify at-risk youth in acute care; effectiveness depends on linkage to assessment and follow-up ^[7], ^[11].

Lethal means restriction

Strong public health evidence: means restriction prevents suicide; integrate into clinical SPI and discharge planning ^[5], ^[12].

Implementation matters

Moderate to strong: Structured implementation strategies (training, workflow integration, spread initiatives) improve adoption and can reduce suicide outcomes across systems ^[11], ^[13].

References

Source material

Primary literature that informs this article.