Turning Tragedy into Learning: A New Approach to Suicide Care Improvement

Nashville, TN — Behavioral health organizations across the country are increasingly seeking better ways to learn from suicide attempts and near-fatal overdoses and apply those lessons to strengthen care.

To support that work, the Center for the Helping Professions (CHP) is partnering with Centerstone’s Institute for Clinical Excellence and Innovation on a new national initiative supported by Four Pines Fund.

The effort aims to help behavioral health organizations learn from suicide attempts and near-fatal overdoses through a systems-focused approach that strengthens care, improves coordination, and reduces preventable harm.

Every suicide attempt and non-fatal overdose leaves important questions for organizations seeking to provide the safest and most effective care possible. This initiative will help behavioral health providers examine those events through a systems-focused lens, identify opportunities for learning and improvement, and strengthen care for the individuals and families they serve.

The initiative will adapt and implement a systems-focused critical incident review methodology specifically for behavioral health settings, helping organizations move beyond blame-focused responses and toward learning-oriented practices that identify patterns, improve coordination, and strengthen care. The project will also establish a national technical assistance hub to support organizations conducting robust reviews and analyses of suicide attempts and non-fatal overdoses.

CHP, a nonprofit organization that helps human service and behavioral health organizations apply safety science and systems improvement approaches to strengthen outcomes and reduce preventable harm, will help guide the adaptation and implementation of the review methodology. Drawing on its experience supporting organizations and public systems across the country, CHP will assist participating organizations in applying safety science principles to strengthen culture, improve outcomes, and reduce preventable harm.

Centerstone will house the technical assistance hub within its federally certified Patient Safety Organization, creating a confidential environment where participating organizations can share patient safety and quality improvement information and learn from one another’s experiences. The project will incorporate perspectives from patients, families, and clinicians to build a fuller understanding of the conditions and system factors surrounding suicide attempts and overdoses.

“This work matters because every suicide attempt and overdose represents a person, a family, and a community navigating unimaginable pain,” said Michael Cull, CEO of the Center for the Helping Professions. “At CHP, our mission is to support the helping professions and the people doing this work every day. We believe providers need tools and learning environments that help professionals respond with compassion, clarity, and continuous improvement, not fear or blame. We’re proud to partner on work that strengthens care, supports the workforce, and helps save lives.”

This effort is one of a collective of five grants made by Four Pines Fund in 2026 to accelerate the national implementation of effective suicide care practices in health organizations.