by Donna Vanderpool, MBA, JD

Ms. Vanderpool is the Director of Risk Management at Professional Risk Management Services (PRMS).

Funding: No funding was provided for the preparation of this article.

Disclosures: The author is an employee of PRMS. PRMS manages a professional liability insurance program for psychiatrists.

Innov Clin Neurosci. 2022;19(10–12):58–59.

This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation and other resources offered to health care providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers might provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other health care professionals so “clinician” is used to indicate all treatment team members.

Answer

We have 25 tips to share with you to hopefully reduce the stress you are experiencing. The first five tips are administrative, but they can go a long way in avoiding very stressful situations. The other 20 tips address your greatest professional liability risks—treating patients with suicidal behaviors and psychopharmacology. These tips are easy to implement, and you may already be doing them.

Administrative Reminders

  1. Ensure all of your licenses, controlled substance registrations (both Drug Enforcement Administration [DEA] and state, if applicable), and professional liability insurance policies are current.
  2. Have a plan to track renewal deadlines for all of your licenses, registrations, and insurance policies.
  3. Ensure all of your regulators (federal DEA, state licensing boards, and state controlled substance authorities, if applicable) have your current address.
  4. Ensure your professional liability insurance company has your correct address so that you will receive all important notices and renewal applications and are covered at the location where you are currently practicing.
  5. Ensure you have current contact information for patients and their emergency contacts.

Suicidal Patient Reminders

  1. Know the criteria and procedures for involuntary hospitalization in all jurisdictions where you practice. The time to figure this out is before you need the information, not when you realize during an appointment that a patient needs to be hospitalized.
  2. Familiarize yourself with the policies of all hospitals or other facilities where you treat patients. It is particularly important to determine each facility’s definition of “close observation,” as some facilities may define it as 1:1, others as 15-minute checks, or something else. Also determine whether your order automatically ends at a certain time if it is not renewed.
  3. Assessment is key. Consider using a formal suicide risk assessment tool for consistency and thoroughness. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends two such assessment tools: the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) tool and the Columbia Suicide Severity Rating Scale (C-SSRS).
  4. Consider whether you should attempt to obtain and review past treatment records for a new patient. If you are unable to obtain records, document your efforts to do so. Prior treatment records can offer a nuanced view of treatment efforts and may provide information you would not otherwise learn.
  5. Do not rely solely on “no harm” contracts as a guarantee of patient safety. It may be appropriate for such a “contract” to be one part of a comprehensive treatment plan, but it is the clinician’s responsibility to evaluate the patient’s overall suicide risk and ability to participate in the overall treatment plan.
  6. Never alter or destroy a record after a suicide. If there is a correction or amendment you think should be made, do not make it until you have obtained advice from your liability insurance company or defense attorney.
  7. Prepare your patients for your scheduled absences. Prepare your covering colleague as well by discussing your high-risk patients.
  8. Remember that listening to others is not breaching patient confidentiality. If you receive a call from a patient’s family member or someone else who wants to share information with you, and you do not have permission to communicate with that person, you can tell them you cannot confirm the person is a patient and listen to what the caller wants to tell you. 
  9. Communication with other clinicians in a split treatment arrangement is often beneficial and may be necessary, especially in the event of emerging suicidal ideation or behaviors.
  10. Educate the patient and, if appropriate, family members or significant others on who to call if a patient feels like hurting their self. Resources include:
    • 988 Suicide and Crisis Lifeline
      • 988
      • 800-273-TALK (8255)
      • En Espanol: 888-628-9454
      • Veterans’ Crisis Line: 988 (press 1)
    • The Trevor Project for LGBTQ youth:
      • 866-488-7386
      • Text START to 678-678

Psychopharmacology Reminders

  1. Check the Prescription Monitoring Program each time prior to prescribing a controlled substance, even if you are not technically required to do so; it is a great patient safety strategy. No matter how well you know your patient, you could always be surprised by what you find.
  2. Do not prescribe large amounts of medications solely because the patient gets better insurance benefits/pays less. Bulk prescriptions may be fine for many patients, but they are not appropriate for all. The standard of care is based on the patient’s clinical needs, not insurance benefits.
  3. Check your e-prescriptions to ensure accuracy prior to sending them. Data entry errors, such as with drop down boxes, are common and have the potential to cause patient harm.
  4. Read the United States (US) Food and Drug Administration (FDA) labels for the medications you prescribe. Not only is this clinically useful, but if you are ever alleged to have been negligent in prescribing, you will almost certainly be asked if you have read the drug label. You want to be able to respond under oath in the affirmative.
  5. Sign up for MedWatch1 to get medication safety alerts from the FDA. As appropriate, discuss new safety information with your patients. Remember to document the discussions, along with any changes to medication monitoring that are needed, such as lab testing, more frequent visits, consults with other specialists, etc.
  6. Be alert to potential abuse and/or diversion of controlled substances. An excellent resource from the DEA is Recognizing the Abuser.2
  7. When continuing a medication started by another prescriber, obtain the patient’s informed consent. You should not presume your patient has been advised of the risks of the medication or other treatment options.
  8. Alert patients to any impact that a new medication may have on their driving, and document this discussion. You are not responsible for ensuring patients do not drive, but you are responsible for discussing the possible impact of the medication on driving when going over risks in your informed consent discussions.
  9. Ensure any lab work you order, such as lithium levels, is done and reviewed by you. Tracking lab work, or, more accurately, failing to track lab work, is not an uncommon factor in lawsuits against psychiatrists.
  10. At each visit, ask whether the patient is on any new medications—both prescription and over-the-counter. Also ask about any supplements the patient may be taking, as patients may not think of them as medication.

References

  1. United States Food and Drug Administration. MedWatch: the FDA safety information and adverse event reporting program. 5 Nov 2022. https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program. Accessed 7 Nov 2022.
  2. Drug Enforcement Administration. Recognizing the abuser. https://www.deadiversion.usdoj.gov/pubs/brochures/pdfs/recognizing_drug_abuser_trifold.pdf. Accessed 7 Nov 2022.