As many as 1 in 10 individuals who die by suicide were seen in an Emergency Department (ED) within the prior two months. Consequently, there has been a national push in recent years for universal screening for suicidal ideation (SI) in all EDs. However, few hospitals have adopted or enforced this guideline, despite research showing that it can double detection of SI and related behaviors. The goal of this project is to investigate the conditions under which screening occurs with a patient at high risk for suicide using a case example of a patient who presents to the ED with injuries caused by a suicide attempt (SA).