Identifying and Reducing Professional Liability When Treating Older Adults
Actions You Can Take to Decrease Risks While Increasing Patient Safety

Jacqueline M. Melonas, RN, MS, JD and Charles D. Cash, JD, LLM, ARM

Professional Risk Management Services (PRMS), Inc in Arlington, Va, manages The Psychiatrists’ Program, the APA-endorsed professional liability program. Ms Melonas, PRMS Vice President of Risk Management, has provided risk management programs for long-term–care providers, rehabilitation faciladmissionsities, and individual health care providers. Ms Melonas has consulted, written, and spoken nationally on various health care law and risk management topics. She received her law degree from the University of Maryland School of Law, Baltimore. Mr Cash, PRMS Senior Risk Manager, received his law degree from Quinnipiac College School of Law, Hamden, Conn, and his Master of Laws in Health Law from DePaul University School of Law, Chicago. Mr Cash regularly contributes to publications and speaks at national seminars on risk management in psychiatry. He also offers risk reduction strategies to psychiatrists via the Risk Management Consultation Service. The authors report no conflicts of interest concerning the subject matter of this article.

Acknowledgment–The authors gratefully acknowledge the assistance of Marynell Hinton, MA, ARM, Senior Risk Manager, PRMS, Inc. in the preparation of this article.

---

Psychiatrists should understand and be knowledgeable about current intervention techniques and professional standards and guidelines for treatment of older patients. Several of the organizations listed in the reference section offer guidelines for the treatment of older patients.

Falls
One surprise finding from this review was the number of psychiatrists who were sued because of patient falls. Falls triggered 20% of the lawsuits we reviewed. Falls are common among older adults and can cause serious injury and death.¹¹ Psychiatrists who treat older patients should be aware of this significant health concern and focus on patients’ clinical needs in this area. There may prove to be a relationship between falls, ADEs, and comorbidities.

Patients should be assessed for comorbidities that might increase their risk for falls. A low threshold for referral to other appropriate providers is probably in order. Two examples from the CDC are yearly eye examinations for older patients and a review of medications to reduce or prevent adverse effects and interactions.¹¹ The use of minimum effective dosages of potentially sedating medications is good clinical practice, particularly with patients at risk for falls.¹²

Patients and significant others should be counseled and warned about the risk of falls as part of the informed consent process. Patients may need to take steps to “fall proof” their homes.

Involuntary Hospitalization
Every state provides for involuntary hospitalization. The criteria usually stipulate that the individual must bementally ill and constitute a danger to himself or others. Some states have additional bases for involuntary admission of individuals, such as those who are gravely disabled.

Lawsuits regarding involuntary hospitalization are relatively rare. Allegations tend to fall into 2 types:

• Legal processes or procedures were not followed.
• Admission was based on a faulty evaluation.

There are several actions psychiatrist scan take to reduce this risk:
•Know and follow the appropriate legal procedures when effectuating patients’ involuntary admissions
•Carefully assess patients who are candidates for involuntary hospitalization.
•Consult with a colleague. Consultation can be invaluable, especially when a standard is vague or when it is not clear that the individual meets the standard.
•Thoroughly document the assessment and the procedures followed.

It goes without saying that involuntary hospitalization should only be used for patient care purposes.

Addressing and reporting elder abuse and neglect
Elder abuse and neglect have been recognized as major public health problems.¹³ Assessment and appropriate intervention are key factors for good clinical care and, therefore, good risk management. The American Psychiatric Association recommends a comprehensive biopsychosocial assessment of the victimized or neglected older person.¹³ Psychiatrists should focus on the clinical needs of the patient and be prepared to refer to other specialists.

One aspect of intervention may include reporting to authorities. More than half of the states have some form of elder abuse and neglect reporting law. The risk management in this area is straightforward: know the appropriate state’s law regarding reporting obligations. The National Center on Elder Abuse offers state-specific resources.

Impaired drivers
The issue of driving while impaired is a consideration with older patients, both as it relates to the normal aging process and to the prescription of sedating medications. Although not reflected in the survey of lawsuits, risk managers see this issue as an emerging trend.¹⁴

As always, good clinical care and risk management involves assessment, patient education, and good medication choices.¹⁵ When there is concern about possible impairment, it may be necessary to refer the patient to a specialist to explore the underlying basis of the impairment and to treat it.

When impairment is a result of a medication adverse effect, use of the minimum effective dosage of the medication might be helpful. Whether the impairment is the result of a medication or an underlying medical condition, the patient should be counseled as part of the informed consent process about the risks of driving and be advised not to drive while impaired.

Pages: 1  2  3  4  

Previous Next