Psychiatry - November 2008 - (Page 50)

[risk management] actions fall below the standard of care, but there is no injury, then there is no malpractice. There is only negligence. Also, a psychiatrist can use proper professional judgment and there may still be a bad outcome (e.g., a bad reaction to a medication). A bad outcome is not itself evidence of malpractice, as exemplified in the adage “the operation was a success, but the patient died anyway.” Proximate cause. The patient’s damages are a direct result of the physician’s negligence. This element is often the crux of a lawsuit. The plaintiff must show that his or her injuries were the result of the defendant’s actions. The concept of proximate cause is grounded in foreseeability. If the patient’s injury was a foreseeable consequence of the negligence, the psychiatrist will be held liable. If the patient’s injury was not foreseeable, or if some intervening act was the catalyst for the injury, the psychiatrist will not be held liable. This is usually the most difficult element to prove. Scenario. Here is a simplistic example to illustrate the elements: A patient was hospitalized after attempting suicide. Four days later, he was discharged from the hospital and committed suicide a few hours later. The representative of the estate is suing the psychiatrist who discharged the patient. The following demonstrate the argument that will be made by the plaintiff: 1. Duty of care That the psychiatrist had a duty to perform a suicide assessment on the patient prior to discharge 2. Breach of duty That the psychiatrist discharged the patient without performing a suicide assessment 3. Damages That the patient died as a result of suicide after being discharged 4. Proximate cause That but for the psychiatrist’s failure 50 Psychiatry 2008 [ N O V E M B E R ] to conduct the suicide assessment prior to discharge, the patient would not have committed suicide (i.e., if the psychiatrist had done his job, this would not have happened). As mentioned previously, the plaintiff must prove all four elements in order to prevail. QUESTION: I know my patient care must always meet the standard of care, but how exactly is the standard of care defined and determined? ANSWER: The exact definition of standard of care varies by state, but generally, it is the degree of skill, care, and diligence exercised by members of the same profession or specialty practicing in light of the present state of medical science. It is important to keep in mind that the standard of care does not mean optimal care, but includes a range of acceptable treatment options. There are many factors that could be used as evidence of the applicable standard of care for a particular patient care issue. These factors that determine the applicable standard of care include, but are not limited to, the following: • Federal and state statutes—such as federal and state prescribing laws • Federal and state regulations—such as regulations from your state medical board, the Food and Drug Administration, or the Drug Enforcement Agency • Other statements from federal and state regulatory agencies—such as guidance documents, position papers, or policy statements from your state medical board • Authoritative clinical guidelines— such as the American Psychiatric Association’s (APA) practice guidelines (www.psych.org) or the American Academy of Child and Adolescent Psychiatry’s (AACAP) practice paramenters (www.aacap.org) • Statements/joint statements from professional organizations—such as the PhysiciansMedGuide, a joint statement by the APA American Psychiatric Association and the AACAP (and endorsed by numerous other professional organizations), which addresses the treatment of children with depression (www.physiciansmedguide.org) • Medical code of ethics • Treatises • Content of continuing medical education activities • Current professional literature and journals • Accreditation standards—such as Joint Commission standards (www.jointcommission.org) • A facility’s own policies and procedures • Physicians’ Desk Reference and FDA-approved drug labeling. In psychiatric malpractice litigation, the standard of care is established primarily by psychiatrists in the role of the expert witness. The expert witness will base his or her opinions on the aformentioned items evidencing the applicable standard of care, his or her own clinical experience and education, and the clinical record. Accordingly, the psychiatrist’s documentation should support the care that was given and should enable someone else—such as an expert witness—to read the record and know what happened and why. One way to accomplish this is to document not only what happened in treatment and why, but also what actions were considered but rejected and why. QUESTION: The APA and other professional organizations sometimes publish treatment guidelines. The facility where I work maintains policies and procedures that address the treatment of patients. Are these 50 http://www.physiciansmedguide.org http://www.jointcommission.org http://www.psych.org http://www.aacap.org

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Psychiatry - November 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Measuring Adverse Events in Psychiatry Nonsuicidal Self Injury in Adolescents Relative Tolerability of Alzheimer's Disease Treatments Biracial Identity Development and Recommendations in Therapy Depression and Cardiovascular Disease: Just an Urban Legend? Three Risk Management Basics Journal Watch Classified Advertising Information for Authors

Psychiatry - November 2008

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