Wide-scale suicide assessments needed to avoid tragedy and significant liability
New patient safety goal puts spotlight on difficult task
Patient suicides don't just happen on locked psychiatric wards. They can happen in your emergency department, your critical care unit, or virtually any area of any health care facility. That characteristic is what makes the suicidal patient so difficult to detect and protect: They could be anywhere.
With suicides distressingly common in health care, and the potential liability huge, the topic should be at the top of any risk manager's list of concerns, experts say.
Suicide prevention has always been important, but a new National Patient Safety Goal from the Joint Commission on Accreditation of Healthcare Orga-nizations is putting a renewed emphasis on this important task. The National Patient Safety Goal, which became effective on Jan. 1, 2007, states that "the organization identifies safety risks inherent in its patient population," and "the organization identifies patients at risk for suicide. [Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.]" (For more information, go to www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_hap_cah_npsgs.htm.)
Unfortunately, patient suicide is not such a rare event. In fact, patient suicide is the No. 1 sentinel event reported to the Joint Commission, accounting for 13.2% of all sentinel events between Jan.1, 1995, and March 31, 2006. Those figures should prompt risk managers to take the National Patient Safety Goal quite seriously, says the immediate past president of ASHRM, Peggy B. Martin, ARM, MEd, DFASHRM, senior risk management coordinator with Lifespan Risk Services in Providence, RI.
Risk managers typically are not involved in the direct assessment of a patient for suicide risk, but they must ensure that proper policies and procedures are in place, Martin says. Exactly what policies and procedures are appropriate will vary from one facility to another, she notes, because the risk of suicide is so different depending on the patient population. A health care facility with a dedicated psychiatric or mental health service will have a higher risk of suicidal patients, but even acute care hospitals and virtually any other type of health care facility still must be on guard.
"People think of all the precautions that are necessary on a psychiatric unit, but it can actually be harder to implement safeguards on other units," Martin says. "On a psych unit, everyone knows there is a risk with a high percentage of patients and you can take some universal precautions with everyone to screen and prevent suicide. In other departments you have to know when to screen and who to screen, and that can be a challenge."
Martin says risk managers should conduct risk assessments on all units that may treat patients at risk for suicide, with psychiatric units being the most obvious example. In those units, the physical environment should be configured so as to reduce the opportunity for suicidal behavior, with locked doors, limited access to items that could be harmful, and clear lines of vision for staff. All of those safeguards can be good on other units where the risk is less severe, but the risk manager will have to make some judgment calls.
"You can't treat every unit in your facility like a lock-down psychiatric unit," Martin says. "The physical safeguards won't always be practical, so that's where you have to depend on the expertise of your staff."
That dependence means you should ascertain how well clinical staff members assess suicidal behavior in patients, Martin says. While all physicians and nurses are trained to recognize suicidal tendencies, they may not always take the time — or have the time — to screen patients properly. Martin suggests meeting with physician and nurse leaders in the departments where suicidal behavior is most likely to occur, emphasizing the risk and the need to have a proactive plan for screening. A good place to start is the emergency department, because the high percentage of patients with drug or alcohol problems increases the risk, Martin says.
"Do they have a policy on looking for these patients at risk, and do they do it systematically instead of just waiting for very obvious signs? There should be an assessment in the emergency department and again if the patient is admitted," she says. Once a patient is found to be at risk of suicide, the provider is obligated to certain precautions such as putting him on suicide watch and taking away his belt and shoelaces, Martin says. "There must be clear policies that are triggered when a risk is detected."
Documentation could save the day
Documentation also is a major concern with patient suicides. Martin explains that if a patient does commit suicide, the liability will hinge on whether the provider knew or should have known about the risk and whether adequate precautions were taken.
"Sometimes if patients are really determined to kill themselves, they will find a way no matter what you do," she says. "It is critical that the documentation be good enough to prove in court that you did everything you could, that you detected the suicidal behavior and did everything reasonable to stop it. That's where a risk manager can have real influence, by requiring top-notch documentation in these cases."
Martin notes that a patient suicide can be devastating to the clinicians on the unit, with far-reaching consequences to the institution, so the policy should include assessment and counseling for any caregivers who might be affected.
Health care providers have a special obligation to protect suicidal patients, but only when they could reasonably have foreseen that the patient was at risk, explains Stephanie Resnick, JD, a partner in the litigation group of the law firm Fox Rothschild in Princeton, NJ. The simple fact that a patient commits suicide while under your care doesn't automatically make you liable.
"When you get into what the doctor should have reasonably foreseen, that is completely fact sensitive," Resnick says. There is no "hard-and-fast" rule, and jurisdictions are split on how they view the question, she says. "The court would look to see how many visits the patient had with the psychiatrist or psychologist, for instance."
The liability for such a case can be huge, she says, and the amount usually depends on how obvious the risk of suicide should have been to the health care provider. Resnick also points out that the suicidal patient sometimes expresses a desire to harm others, which can create an obligation to warn the other party. (See box below for more on the duty to warn.)
Duty to warn related to suicide prevention It is not uncommon for patients who want to die to say that they're going to take someone else with them. Once those words are uttered, a health care provider will have to decide whether to warn the other person, explains Stephanie Resnick, JD, a partner in the litigation group of the law firm Fox Rothschild in Princeton, NJ. "The short answer is that whenever there is a definite statement that the person is going to cause harm to another, then the hospital has to go outside the privilege of the doctor/patient relationship and actually warn the intended victim," Resnick says. "We have faced this with a client, and we got an emergency order that allowed the hospital to disclose the information, and therefore there could be no allegation by the patient that there was a breach of privacy or the physician/patient privilege." This obligation is generally called "the duty to warn." In situations where there is clear evidence of danger to the client or other people, the health care provider must determine the degree of seriousness of the threat and notify the person in danger and others who are in a position to protect that person from harm, Resnick says. The legal precedent of this concept was set in the case of Tarasoff v. Regents of the University of California in 1976. In this case, Posenjit Poddar, a University of California student, was seeing a psychologist at the university's student health center because a young woman, Tatiana Tarasoff, had spurned his affections. When Poddar told the psychologist he intended to buy a gun, the psychologist notified the police verbally and in writing. The police questioned Poddar and found him to be rational; they made him promise to stay away from Tarasoff. Two months later, however, Poddar killed Tarasoff. The Tarasoff family sued, asserting that the defendants had a duty to warn the victim or her family of the danger and that they should have persisted to ensure the man's confinement. The court held that the therapists did have a duty to warn Tarasoff. Resnick notes that the ruling means it is not enough to notify the police. The court imposed an affirmative duty on health care providers to warn a potential victim of intended harm by the client. |
Martin emphasizes that suicide cases can be especially difficult to defend. Risk managers may understand how difficult it can be to protect someone determined to commit suicide, but juries see such cases more simply: The person was under your care, and you let the patient commit suicide.
"We count on documentation of the assessment and whether we followed our own policies, doing what we should have based on the assessment," Martin says. "How available were psychiatric experts to the emergency department staff and other units when a problem occurs? That can be a very big deal."
Other important questions for the defense may include:
- How recently did you conduct a safety assessment of the area in which the person died? What did you find, and did you correct any potential hazards?
- Do you have a safety committee on the unit that continuously oversees safety measures and conducts record reviews?
- Was information about the patient's suicide risk properly handed off from one clinician to another?
Resnick notes that the National Patient Safety Goal ups the ante in terms of the health care provider's obligation. The duty to protect the patient has been clear for some time, but the goal underscores the fact that good medical care requires screening for suicidal intentions. Courts generally will find that there is a lesser duty on nonpsychiatric units such as an emergency department, she says, but there still clearly is a duty.
How much of an assessment, and exactly what type, will depend on the situation and what is practical under the circumstances, Resnick says. In an ideal world, clinicians would have the time to ask all patients a few questions to assess suicide risk, and a good policy would be that you assess all patients for suicide, she says. In the real world, they should conduct at least a broad screening whenever possible, Resnick advises.
"Yes, that kind of assessment will impose a burden on the emergency room, but I think it's good practice," Resnick says. "That doesn't mean you have to do a full-scale psychiatric assessment on all patients, but you probably should observe for any warning signs, ask some general questions, and then follow up as necessary."
Sources/Resources
For more information on suicide assessment, contact:
- Peggy Martin, ARM, MEd, CPHRM, DFASHRM, Senior Risk Management Coordinator, Lifespan Risk Services, The Coro Building, 167 Point St., Suite 170, Providence, RI 02903. Telephone: (401) 444-6491. E-mail: [email protected].
- Stephanie Resnick, JD, Fox Rothschild, 2000 Market St., 10th Floor Philadelphia, PA 19103-3291. Telephone: (215) 299-2082. E-mail: [email protected].
- A Quick Reference Guide to assessing suicidal behaviors from the American Psychiatric Association is available at www.psych.org/psych_pract/treatg/quick_ref_guide/Suibehavs_QRG.pdf. The full guideline is available at www.psych.org/psych_pract/treatg/pg/SuicidalBehavior_05-15-06.pdf. The full guideline contains tables of suicide risk and protective factors as well as a list of example questions to ask suicidal patients in assessing their risk.
- The New South Wales Australia suicide guidelines include information on reviewing risk in the emergency department at www.health.nsw.gov.au/pubs/2005/pdf/emergency_dept.pdf.
- The National Suicide Prevention Lifeline web site offers resources and a national crisis phone number [(800) 273-TALK (-8255)]. Web: www.suicidepreventionlifeline.org.
- The Textbook of Suicide Assessment and Management is available from The American Psychiatric Publishing in Washington, DC. The book includes a chapter on emergency services. The cost of the book (item 62213) is $85 plus $9.95 for shipping and handling. To order, call (800) 368-5777 or go to appi.org. Under "Books," click on "Featured Titles" and then "The American Psychiatric Publishing Textbook of Suicide Assessment and Management."
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