Risk and Safety Issues in Psychiatry XVI reviews the management of patients with an increased risk of suicide. The course explains the need for appropriate coordination, oversight, and documentation of care. Given the importance of sensitive care to a suicidal patient and the ripple effects on their family and treating clinicians, following clinical practice guidelines and hospital rules is imperative. Breakdowns in coordination can lead to negative outcomes, including medication error, treatment discontinuation, poor health outcomes, and even death. This course explores risk mitigation strategies that can be implemented when caring for patients with suicidal ideation and illustrates lapses in the care of 3 patients who died by suicide.