Legal Review & Commentary
Psychotic patient jumps from window: $338,331
News: A Maryland jury awarded $338,331 to a patient who jumped from a third-floor window and survived.
Background: The 42-year-old patient initially was admitted to the hospital's psychiatric ward diagnosed with depression and psychosis. He was administered antipsychotic medication on an as-needed basis. When the patient's psychiatrist learned that the patient was suffering from tertiary syphilis, he ordered the patient transferred to an open medical ward for treatment. Three days later, the patient smashed a window on the third floor and jumped out of it. He sustained numerous fractures. The patient alleged that in light of his psychosis, the psychiatrist negligently transferred him from a locked ward to an open floor. He also claimed that the nurses negligently failed to monitor and protect him. The jury found only the hospital liable.
What it means to you: Damage control in this scenario involves bringing in the risk manager immediately. "This is a big-issue case," says Ricki Strader, RN, JD, director of risk management at Athens (GA) Regional Medical Center.
"To diminish the damages, it needs to be handled properly from the time the patient is injured. The patient needs immediate medical treatment, the area must be secured, the family must be notified in the right way, and the documentation must be done correctly," Strader explains.
The underlying issue in this case is whether the patient was properly assessed on the psychiatric unit and on the open medical unit, Strader says. "The patient needed to have a continuing psychiatric assessment, no matter what unit he was on."
She has several suggestions for making appropriate assessments and otherwise reducing the risk of this type of occurrence. The best strategy is to have a medical-psychiatric unit, but that is not always possible in every facility. "A drastic approach is to transfer high-risk patients to a facility that has a medical-psychiatric unit, if your institution cannot care for them properly," Strader adds. But there are other options to consider if an institution is to have control of this type of problem.
"A nurse from the psychiatric unit could go to the open medical unit and assess the patient every shift. Hopefully, the psychiatrist will assess the patient daily. Staff could be cross-trained in both psychiatry and medical-surgical so that the psychiatric nurses can handle the medical-surgical patients, and the medical-surgical nurses can identify problems with the psychiatric patients," Strader suggests.
He also advises implementing policies and procedures concerning psychiatric patients on the medical-surgical units if transfers happen frequently. "All of the patients' information must be given to the open unit. Moreover, those patients should be placed in rooms closest to the nurses' station, allowing for frequent monitoring. Put them on suicide precautions and use restraints when necessary. Also, sitters are a consideration, as well as increased staffing, monitors, and alarms."
Another important factor is the need to pay closer attention to patients with multiple psychiatric diagnoses. "Someone with a psychosis has poor judgment and reasoning. In combination with depression, this can create an increased risk of suicide," he points out. This raises the issue of medications. "The patient in this case had a PRN psychiatric medication on the psychiatric unit, but was that continued on the open unit? Was he appropriately medicated for his depression and psychosis?"
Strader adds that if a psychiatrist is not going to follow a patient on the open unit, protocols prepared by psychiatrists for use on the nonpsychiatric units probably ought to be available. "We have such protocols available in my facility for alcohol withdrawal, and they are helpful."
Looking at other reporting aspects
The risk manager must address other aspects of an attempted suicide, Strader notes. "How does the occurrence fit into the hospital's sentinel event definition and policy and procedure? Does it need to be reported to JCAHO [the Joint Commission on Accreditation of Healthcare Organizations]? Under JCAHO standards, the facility at a minimum should intensively analyze the incident, and an action plan should be prepared to prevent similar events in the future," Strader says.
Moreover, if the attempted suicide is reported to local law enforcement, media interest could result. The risk manager should suggest that the administration and public relations decide how they are going to respond to requests for information from the media so that an appropriate statement is available in advance, Strader advises.
Finally, because an occurrence like this can involve multiple disciplines, such as security, safety, engineering, the emergency department, and possibly the environment of care committee, there will be other documents the risk manager will have to worry about protecting in litigation, she concludes.
Reference
Albritton v. Washington Adventist Hospital and Fawcett, Montgomery County (MD) Circuit Court, Case No. 147875.
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