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Kyouhei YAMASHITA2), Nobuto SHIBATA4), Tuneyoshi OTA5), Tadashi FUKUSHIMA2)2)Asahinooka Hospital, Kanagawa, Japan3)Home-Visit Nursing Station, Asuka, Tokyo, Japan5)Department of Psychiatry, Juntendo University School of Medicine, Tokyo, Japan4)Department of Psychiatry, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, JapanCorresponding author: Nobuto Shibata (ORCID: 0000-0001-5654-5024)Department of Psychiatry, Juntendo Tokyo Koto Geriatric Medical Center3-3-20 Shinsuna, Koto-ku, Tokyo 136-0075, JapanTEL: +81-3-5632-3111　FAX: +81-3-5632-3728　E-mail: nshibata@juntendo.ac.jp〔Received　Jan. 7, 2022〕〔Accepted　Feb. 9, 2022〕J-STAGE Advance published date: Jun. 9, 2022Copyright © 2022 The Juntendo Medical Society. This is an open access article distributed under the terms of Creative Commons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original source is properly credited. doi: 10.14789/jmj.JMJ22-0002-OAObjective: This study retrospectively explores the objective signs of imminent suicide risk in psychiatric in-patients.Design: The study analysed the diagnostic and nursing records of a psychiatric hospital that covered the last 14 days before the suicide attempts of 18 people, who, between March 2008 and July 2019, were found to have died by suicide during their hospital stay.Methods: Three professionals used a fishbone diagram to separately identify the factors that led to each person’s suicide, the objective signs that indicated imminent suicide risk, possible preventive strategies, and other observations. They compared their findings and used the KJ method (Kawakita Jiro Method) to categorise the items on which they all agreed.Results: Objective signs of imminent suicide risk were condensed into five categories: ‘signs emanating from the patient’, ‘signs gleaned through engagement’, ‘signs from response to treatment’, ‘signs associated with reports from the family’, and ‘signs inferred from multiple sources of information’. Five categories describing issues with the way in which the hospital staff handled information were extracted, namely ‘omission in diagnostic records during admission’, ‘omission in conference records’, ‘communication lapse during transfer’, ‘need for integrated information’, and ‘systemic issues’.Conclusions: The findings offer insights on assessing suicide risk and preventing suicide.Key words: suicide, in-patient, psychiatric hospital, objective signsJuntendo Medical Journal2022. 68(3), 261-270Original ArticlesExploring the Objective Signs of Imminent Suicide Risk in Psychiatric In-patientsIntroductionPsychiatric hospitals play an important role in suicide prevention by protecting and treating people who present a risk of suicide. However, suicides still occur among psychiatric in-patients, with an estimated suicide rate of 147 per 100,000 patients1). Aside from preventing any possibility of treatment, suicides inflict severe trauma on the patients’ families and the people around them, and potentially expose the hospital to litigation. It is 1)Graduate School of Health and Sports Science, Juntendo University, Chiba, Japantherefore essential to prevent suicides among psychiatric in-patients. Although factors causing suicide have been investigated for a long time, the results derived so far present limited sensitivity and low positive predictive value of the combina-tions of risk factors, suggesting that suicide risk models have limited use in clinical settings2-4). For example, Neuner et al. (2008) identified four risk factors of suicide among in-patients, including resistance to psychopharmacological treatment and past suicide attempts, but these could explain 261Hiromi SHIMAZAKI1, 2), Itaru UTAGAWA2), Chiemi SANO3), Shinobu SAKURADA2),