Chapter 13: Risk Management in Psychiatry Psychiatric Care • Healthcare and treatment of persons with acute and/or chronic mental illness • Provided in various types of healthcare settings – Specialty facilities – Special unit in a hospital – Ambulatory centers – Private offices Informed Consent • Psychiatric patients have the right to select their treatment (as do all patient) unless deemed incompetent. • For the patient to be considered competent to consent to treatment, they must be able to: – Communicate a choice – Understand information about the treatment – Recognize the clinical situation – Manipulate information rationally Informed Consent and Research • Research guidelines must adhere to the general informed consent requirements • The National Bioethics Advisory Commission issued a report entitled “Ethical and Policy Issues in Research Involving Human Participants” which outlines basic principles for research studies • The Office for Human Research is another resource for guidelines on obtaining consent, especially for children Right to Treatment • Right to the Least Restrictive Alternative • Closure of Psychiatric Facilities • Involuntary Outpatient Treatment • Medical Necessity • Insurance Coverage • Psychiatric Advanced Directives (PAD) Right to Refuse Treatment All patients have the right to refuse treatment, even patients with mental illness. • Psychotropic Medications • Involuntary Hospitalization • Involuntary Outpatient Treatment Clinical Risks • Psychopharmacology and Side Effects • Electroconvulsive Therapy • Suicide • Discharge and Aftercare Planning • Seclusion and Restraint • Elopement and Wandering • Child and Adolescent Psychiatry Confidentiality and Stigma • Public view of mental illness • Privileged Communication • Duty to Protect/Warn High Risk Incidents • Violence and Mental Illness • Violence in the Institution • Availability of Illicit Substances • Professional Sexual Misconduct • Staff-Patient Sexual Misconduct Other Areas of Concern • Fraud and Abuse • Public Safety • Noncompliance with treatment regimen Summary • Patients with mental illness have the same rights as all patients unless deemed incompetent. • There are additional risk management concerns involved in treating patients with mental illness. Chapter 12: Risk management for Infection Control Programs Goal of Infection Control • To prevent the transmission of infections to patients, visitors and healthcare personnel • In the United States, infection control programs are required by various agencies: – OSHA – CMS – TJC – State and Local Depts. of Health Infection Control Program A formalize infection control program includes • Procedures for determining the risk of transmission of infectious agents • Enforcement or procedures • Protocols to manage the risk The organization’s leadership is responsible for implementing these programs ...

1. Chapter 13: Risk Management in
Psychiatry
Psychiatric Care
• Healthcare and treatment of persons with
acute and/or chronic mental illness
• Provided in various types of healthcare
settings
– Specialty facilities
– Special unit in a hospital
– Ambulatory centers
– Private offices
Informed Consent
• Psychiatric patients have the right to select
their treatment (as do all patient) unless
deemed incompetent.
• For the patient to be considered

2. competent to consent to treatment, they
must be able to:
– Communicate a choice
– Understand information about the treatment
– Recognize the clinical situation
– Manipulate information rationally
Informed Consent and Research
• Research guidelines must adhere to the general
informed consent requirements
• The National Bioethics Advisory Commission
issued a report entitled “Ethical and Policy Issues
in Research Involving Human Participants” which
outlines basic principles for research studies
• The Office for Human Research is another
resource for guidelines on obtaining consent,
especially for children
Right to Treatment
• Right to the Least Restrictive Alternative
• Closure of Psychiatric Facilities
• Involuntary Outpatient Treatment

3. • Medical Necessity
• Insurance Coverage
• Psychiatric Advanced Directives (PAD)
Right to Refuse Treatment
All patients have the right to refuse
treatment, even patients with mental illness.
• Psychotropic Medications
• Involuntary Hospitalization
• Involuntary Outpatient Treatment
Clinical Risks
• Psychopharmacology and Side Effects
• Electroconvulsive Therapy
• Suicide
• Discharge and Aftercare Planning
• Seclusion and Restraint
• Elopement and Wandering

4. • Child and Adolescent Psychiatry
Confidentiality and Stigma
• Public view of mental illness
• Privileged Communication
• Duty to Protect/Warn
High Risk Incidents
• Violence and Mental Illness
• Violence in the Institution
• Availability of Illicit Substances
• Professional Sexual Misconduct
• Staff-Patient Sexual Misconduct
Other Areas of Concern
• Fraud and Abuse
• Public Safety
• Noncompliance with treatment regimen

5. Summary
• Patients with mental illness have the same
rights as all patients unless deemed
incompetent.
• There are additional risk management
concerns involved in treating patients with
mental illness.
Chapter 12: Risk management for
Infection Control Programs
Goal of Infection Control
• To prevent the transmission of infections to
patients, visitors and healthcare personnel
• In the United States, infection control
programs are required by various agencies:
– OSHA
– CMS
– TJC
– State and Local Depts. of Health

6. Infection Control Program
A formalize infection control program includes
• Procedures for determining the risk of
transmission of infectious agents
• Enforcement or procedures
• Protocols to manage the risk
The organization’s leadership is responsible for
implementing these programs.
Healthcare Associated Infections (HAIs)
• HAIs are infections that occur in patients while
they are at a healthcare institution to receive
care
• HAIs are one of the leading causes of death in
the US
• According to the CDC
– 20% of HAIs are preventable
– 1 in 20 hospitalized patient contracts an HAI
Infections in Healthcare Personnel

7. • Generally associated with unprotected exposure
to the blood and bodily fluids of infected
patients
• The OSHA Blood-borne Exposure Standard
requires employers of personnel who may come
in contact with infected blood/bodily fluids to
provide:
– Training to prevent exposures
– Policies for staff to utilize personal protective
equipment
– Vaccination against Hepatitis B free of charge
Risk of Infection in Healthcare Settings
• Infections are naturally concentrated in
healthcare settings
• Infection Control Risk Management is a
proactive process and includes the following:
– Identification of risk of exposure
– Assessment of frequency and severity of exposure
– Elimination of risks as possible
– Minimization of risks which cannot be eliminated
• Major infection control risk management
procedure: Hand Hygiene
Bloodstream Infection Risk
• A vascular catheter is a tube inserted directly

8. into the patient’s vein and are utilized to give
the patient medication, blood or nutrition.
• A central catheter or line is an intravascular
catheter that terminates at or close to the
heart or a great vessel
• Infections in the central line are called known
as Central Line-Associated Bloodstream
Infections (CLABSI) and can be lethal
CLABSI Prevention
• Proper management of the central line can minimize
the risk of CLABSI
• Insertion procedure:
– Use of sterile barrier technique
– Use of proper hand hygiene
– Use of chlorhexidine for disinfecting the skin
– Avoid the femoral insertion site
• Management once inserted:
– Monitor insertion site
– Use of recommended sterile technique
– Scrub the port when entering the catheter to deliver
medication
– Monitor the patient and remove catheter when no longer
needed.

9. Transmission of HIV
• Casual, everyday contact does note expose
one to HIV which is transmitted through
exposure to blood and certain bodily fluids
• Main risk of HIV transmission to healthcare
personnel is through accidental injuries from
needles or other sharp instruments
• Use of universal precautions and personal
protective equipment can minimize the risk of
transmission of HIV
Pneumonia Infection Risk
• Pneumonia is inflammation of the lungs which is
not common in healthy individuals who are
usually able to fight the infection
• Sick individuals, however, are more susceptible
due to their weakened state and may contract
hospital-acquired pneumonia which can be lethal
• It is imperative that healthcare personnel
recognize the symptoms which can mimic the flu
and begin proper treatment as soon as possible
Risk for Tuberculosis
• Tuberculosis (TB) is caused by a bacteria that is
spread from person to person through the air

10. • Healthcare personnel should maintain a high
level of suspicion when working with a patient
with signs and symptoms of TB
– Place patient on airborne isolation
– Utilize personal protective equipment at all times
– Follow-up and evaluate staff that may have been
exposed
Multidrug-Resistant Pathogens
• Multidrug-Resistant Pathogens (MDROs) are
microorganisms that are resistant to one or
more classes of antibiotics.
• In other words, they are difficult to treat as
there are no effective antibiotics available.
– MRSA
– VRE
– ESBLs
– C. difficile
Outbreaks in Healthcare Settings
• Risk Managers monitor infection data to
identify outbreaks (abnormal level of infection)
• Common causes of outbreaks include
– Noncompliance with infection control protocols
– Environmental sanitation
– Contaminated equipment or supplies

11. – Inadequate cleaning of equipment
– Vaccinations
Implications of Effective Infection Control
• Reduced risk of malpractice litigation
• Improved safety for patients, visitors and
healthcare personnel
Summary
• Infection Control is an important function of
risk management and is mandated by various
federal and state agencies
• Effective infection control can reduce the risk
of malpractice litigation and improve the
safety of patients, visitors and healthcare
personnel
Chapter 11: Risk Management in
Selected High-Risk Hospital Depts
High Risk Depts. in Hospitals
• All clinical depts. in hospitals have

12. potential for risk, but some are greater
than others:
– Emergency Room
– Obstetrics and Neonatology
– Surgery and Anesthesia
– Diagnostic Imaging
• Treat highly vulnerable patients in often
chaotic settings where the results of errors
can be catastrophic and costly
Emergency Medicine
• Which Definition?
– AMA – any condition clinically determined to require
immediate medical care
– Federal Legislation – condition manifested by acute
symptoms of sufficient severity that the absence of
immediate medical attention could reasonably be
expected to result in serious jeopardy to an
individual’s health, serious impairment to bodily
functions or serious dysfunction of any body organ or
part
– Clinicians –view emergencies as life-threatening
situations
• The mere existence of an ER implies a

13. duty to treat any patient who arrives
Emergency Medicine Issues
• Emergency Medical Treatment and Active
Labor Act (EMTALA)
• Pre-hospital services
• Dept Capabilities and Staffing
• Triage Process
Emergency Medicine Issues
• Medical Records Documentation and
Consent
• Support Services
• Departures, Discharges and Transfers
• Risk Management
Obstetrics and Neonatology
• Lawsuits in this category are usually the

14. most expensive
– Advanced technology has improved survival
rates for infants but led to increased risks for
facilities
• Ethical Dilemmas
• Standards and Guidelines
• Levels of Care
– Level 1 – least intensive and designed to treat
low-risk mothers and babies
– Level 2 – must be able to manage high-risk
mothers, high-risk fetuses and small, sick
neonates
– Level 3 – must be able to monitor and
maintain critical functions of mothers and
neonates the nurse to patient ratio is more
intensive as well
Obstetrics and Neonatology
Obstetrics and Neonatology
• Prenatal and Perinatal Care

15. • Intrapartum Period
• Delivery
• Neonatal Resuscitation and Management
• Maternal Exam Post Delivery
• Family Attendance Issues
Obstetrics and Neonatology
• Medical Record Documentation
• Neonatal Services
• Infant Transport
• Infant Abduction
Surgery and Anesthesia
• Surgery and Anesthesia claims are usually
co-dependent
• Increased number of surgeries performed
in outpatient or ambulatory settings with
decrease in number of claims

16. • Paid malpractice claims are higher in the
outpatient setting
Surgery and Anesthesia
• Negligence and Malpractice
• Surgical Services Staff
• Preoperative Assessment and Treatment
• Intraoperative Risks
• Postoperative Recovery
• Documentation
Surgery and Anesthesia
• Intraoperative Risks
– Sedation and Anesthesia
– Wrong Site, Wrong Procedure, Wrong Person
– Implants
– Retained Foreign Bodies
– Patient Burns and Pressure Injuries

17. – Surgical Fires
Diagnostic Imaging
• Creating images of the human body utilizing
various methods:
– X-rays
– Computed tomography (CT)
– Interventional radiography
– Ultrasound
– Magnetic resonance imagine (MRI)
– Positron emission tomography
Diagnostic Imaging
• Malpractice allegations
– Failure to diagnose
– Misdiagnosis
– Wrong diagnosis
• Errors
– Scanning -- Satisfaction of search

18. – Recognition -- Visual perception
– Decision making -- Influential perception
Diagnostic Imaging
Radiation exposure: GOAL - as low as
reasonably achievable
– Decrease time of exposure
– Increase distance of the patient and staff from
radiation source
– Use proper shielding
Summary
• These high-risk areas in the hospital should
be carefully reviewed for appropriate policies
and procedures as well as compliance with
them
• Communication and good customer service
with patients is key in these high-risk areas
• Documentation is imperative in all areas but

19. especially in high-risk departments which
tend to have a higher likelihood of litigation
Chapter 10: Strategies
to Reduce Liability
Managing Physicians
• Facilities may have liability when a
physician is involved in malpractice
– Respondeat superior
– Ostensible agency
– Corporate negligence
Professional Practice Acts
• Regulatory boards
– Created by State legislation
– Statute defines the scope of professional
practice and specifies:

20. • Composition of the board
• Duties and powers to create rules for the
professional practice
• Licensure process
• Continuing education requirements
• Investigation and disciplinary actions
Professional Discipline
• Regulatory Board will:
– Investigate suspected misconduct
– Prosecute confirmed misconduct, as
appropriate
– Take appropriate disciplinary action for
confirmed misconduct
• License revocation
• License suspension
• Fines
• Referrals for professional assistance

21. Examples of Misconduct
• Repeated acts of negligence
• Incompetence
• Aiding or abetting the unlicensed practice of
medicine
• Failure to comply with government
rules/regulations
• Exploitation of the patient for financial gain
• Evidence of moral unfitness to practice
medicine
Examples of Misconduct
• Failure to maintain appropriate medical
records
• Abandoning or neglecting a patient
• Harassing, abusing, or intimidating a
patients
• Ordering excessive tests or treatments

22. • Unlawful use of controlled substances
Physical impairment of professionals
• Health problems, disease, disability,
psychiatric issues, and alcohol/chemical
abuse
• Symptoms of impairment
– Making rounds late --complaints from staff
– Inappropriate orders -- frequent accidents
– Hostile behavior -- mood swings
– Personal hygiene -- job changes
– Neglected social commitments
Sexual Harassment
• Providers are in the unique position of
power
– Patient is dependent on the provider

23. Identifying Previous Misconduct
• Licensing boards share information
concerning adverse actions against
providers across state lines
– The Federation of State Medical Boards
– National Practitioner Data Bank
• Risk Managers should ensure that the
facility hiring and credentialing policies
include a procedure for checking the data
banks
National Practitioner Data Bank
• Designed to collect comprehensive data on
adverse actions taken against health care
practitioners, malpractice payments made
and Medicare/Medicaid exclusions.
• Insurance companies and hospitals are
required to report to DHHS and state
licensing boards any medical malpractice
payments resulting from court judgments or
settlements
• Facilities are required to check the NPDB for
all new medical staff and every two years for
re-credentialing
• 4 classes of adverse actions requiring

24. reporting
– Those taken against a practitioner’s license by
a state medical board
– Those taken against a practitioner’s clinical
privileges at a health care facility
– Those taken against membership by a
professional society
– Those taken by Medicare/Medicaid and the
DEA
National Practitioner Data Bank
Clinical Practice Guidelines
• Systematically developed statements to assist
practitioners and patient decisions about
appropriate health care for specific clinical
circumstances.
– Private Initiatives
– Government Initiatives
– Worker’s Compensation
– Medical Liability Insurers
• Risk managers must not only be aware of
clinical practice guidelines, but also the legal
implications of ignoring them

25. • Health professionals reviewing other like
health professionals to assess:
– Quality concerns
– Hospital privileging decisions
– Group practice membership decisions
– Staff conduct
– Professional isolation
– Education
Peer Review
Liability Alternatives
• Limit number of lawsuits
• Control size of awards
• Limit access of plaintiffs to the system
Removal of Malpractice
Litigation from Judicial System
• Several tort reform proposals recommend

26. shifting malpractice litigation away from the
judicial system
– Administrative Agencies
– Alternative Dispute Resolution
No-Fault Proposals
• Under this type of system, adverse outcomes
would be automatically compensated without
lawsuits regardless of whether the outcomes
resulted from negligence.
– Accelerated Compensation Events
– Enterprise liability
– Other methods
Summary
• Risk Managers must work with the
healthcare professionals in terms of
practice guidelines and peer review.
• Proactive liability reduction can offer
significant protection of the organization’s

27. financial resources.