Unit watch over suicidal patients by nonmedical soldiers is often necessary in a deployed environment, but this strategy's risks may outweigh its benefits in a garrison environment. This case study illustrates risks of unit watches that are difficult for medical personnel to effectively mitigate. The suicidal soldier in question was placed on a unit watch in lieu of psychiatric hospitalization, utilizing a plan agreed upon by all parties. However, within 2 days, the plan had degenerated to an unacceptable degree. A commander is always legally responsible for subordinate soldiers' conduct, but from a patient safety perspective, medical professionals must account for the inevitable periods of decreased oversight within a unit. Medical professionals who recommend a unit watch must consider the risks associated with this course of action, including instances such as the error chain detailed in this case.
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