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Old Problems, New Solutions


CSAC Excess Insurance Authority Annual Medical Malpractice Programs Training Wednesday, April 23, 2008 9:00 a.m. - 4:30 p.m. Sacramento, CA Hospice Care Care for ... – PowerPoint PPT presentation

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Title: Old Problems, New Solutions

Old Problems, New Solutions
  • CSAC Excess Insurance Authority
  • Annual Medical Malpractice Programs Training
  • Wednesday, April 23, 2008
  • 900 a.m. - 430 p.m.
  • Sacramento, CA

  • Michael Fleming, ARM, Chief Executive Officer,
    CSAC Excess Insurance Authority

  • Handouts
  • CEUs Sign-in Sheets
  • Travel reimbursement forms
  • Electronic evaluation form
  • Questions
  • Breaks, lunch
  • Bathrooms, public telephones
  • Cell phone reminder

  • Legal and Risk Management Update
  • Tort Reform MICRA Update
  • Falls, Wandering, Elopements and AMA
  • Medication Errors
  • Correctional Care - Pre-Booking Medical Costs
  • Combining Mental Health and Substance Abuse
  • HIPAA Update/Confidentiality Concerns
  • Advance Directives for Healthcare
  • Hospice Care

  • www.csac-eia.org
  • California State Association of Counties Excess
    Insurance Authority - check out Resources (Best
    Practices Library) and Services (Loss Prevention)
  • www.rmscotati.com
  • Risk Management Services - use links button
  • www.leginfo.ca.gov
  • California statutes - x one Code at a time,
    then search for table of contents

  • www.calregs.com
  • California Code of Regulations (CCR) - helpful to
    know which Title and Section number
  • www.cdcr.ca.gov
  • California Department of Corrections and
    Rehabilitation - click on Corrections Standards
    Authority and then, (on left side) click on
    Regulations then find Adult and Juvenile Health
    Regulations and Guidelines

  • www4.law.cornell.edu
  • click on Federal Constitution, US Code (laws), or
    CFR (Code of Federal Regulations)
  • www.coce.samhsa.gov
  • U.S. Department of Health and Human Services,
    Substance Abuse and Mental Health Services
    Administration (click on COCE - SAMHSAs
    co-Occurring Center for Excellence)

  • www.youthlaw.org
  • National Center for Youth Law
  • www.calhealth.org
  • California Hospital Association (click on
    publications and then forms and posters)
  • www.californiahia.org
  • California Health Information Association (click
    on publications)

  • www.lac.org
  • Legal Action Center, click on publications to
    get to Confidentiality and Communication (2006
    edition), A Guide to the Federal Drug and Alcohol
    Confidentiality Law and HIPAA

Legal Update New Laws, Regulations, and
  • Linda Garrett, JD
  • Risk Management Services
  • 905 a.m. - 1000 a.m.

Update Laws, Regs, Risk Management Issues
  • Records retention
  • Confidentiality
  • HIV Consent
  • Mental Health
  • Errors/Hospital Acquired Conditions

Records Retention Proposed new legislation
  • SB 1415 - An action to add
  • HS Code 123106
  • a) 10 years minimum records retention
  • b) at time record is created, patient may elect
    to have record archived longer than 10 years
  • c) no fewer than 60 days before records are
    destroyed healthcare provider must notify the
    patient and ask if theyd like them archived!

Records Retention - Old Law - New Solution
  • Clinic records should be maintained, at a
    minimum, for 7 years past the last date patient
    is seen, or in the case of minors, until 1 year
    past the age of majority, whichever is longer
  • 1/1/07 - Business and Professions Code 2919
    Psychologists records for minors must be
    retained until minor turns 25 years of age! Most
    providers keep until year that client would turn

  • Most counties now keep all minor records that
    include mental health services according to this
    rule so that they dont have to search each
    record for notes that might have been written by
    a psychologist

Speaking of records
  • Be careful who you contract with to destroy the
    records, and who you contract with to transcribe
    records - beware the overseas subcontractor!
  • Make sure you have a Business Associate Agreement
    and hold harmless language in the contract and
    that company has adequate insurance coverage and
    you have proof of insurance (certificate)

  • Domestic Violence Victim-Counselor Privilege
  • SB 407 clarifies and strengthens the definitions
    of domestic violence victim-counselor privilege
    and extends it to communications to domestic
    violence counselors not previously included in
    the definitions (amends Evidence Code sections
    1037.1, 1037.2, 1037.4 and 1037.5 also Penal
    Code 679.05)

Sharing medical info about 300 or 600 kids
(dependents or wards)
  • AB 1687 amends Civil Code 56.10 by adding 56.103
    to permit disclosures of information about
    children and youth that is protected under CC
    56.10 to a county social worker, probation
    officer or other person legally authorized to
    have custody or care of a minor for the purpose
    of coordinating health care services and medical
    tx provided to the minor.
  • LPS Act (county mental health) info NOT covered
    by this new law (

HIV disclosures
  • Written authorization normally needed to disclose
    HIV test results and related info
  • Exceptions to this rule include
  • To the patient or patient representative (e.g.,
  • To the health care provider (ok to include in
  • To an agent or employee of the provider who
    provides direct patient care and tx

  • Exceptions (continued)
  • To a provider under the Uniform Anatomical Gift
  • Pursuant to an organ donation
  • Anonymously to a designated officer under the
    Ryan White Act when there has been a possible
    first responder exposure
  • After an occupational exposure, following strict
  • Under certain Penal Code sections w/court order
    or search warrant

HIV Consent to Testing
  • Law now says a physician treating a patient must
    obtain INFORMED (rather than using the word
    WRITTEN) consent
  • Everyone else (other than alternative/anonymous
    site, blood bank or plasma center) must get
    written consent
  • Old solution the best way for a physician to
    demonstrate and prove informed consent, is to get
    it in writing!

Mental Health
  • 5150 Update
  • SB 916 allows non-designated hospitals to detain
    individuals who are danger to self, others or
    gravely disabled, up to 24 hours while they look
    for a 72 hour involuntary bed to transfer the
    patient to.

  • Note this is not a hold -- it is merely
    protection from litigation for false imprisonment
    if an individual is prevented from leaving for up
    to 24 hours while a transfer is arranged - the
    hospital can choose to let the person leave
    sooner if the condition is stabilized

Health and Safety Code 1799.111
  • 1799.111. (a) A licensed general acute care
    hospital, that is not a county-designated
    facility pursuant to Section 5150 of the Welfare
    and Institutions Code, a licensed acute
    psychiatric hospital, that is not a
    county-designated facility pursuant to Section
    5150 of the Welfare and Institutions Code,
    licensed professional staff of those hospitals,
    or any physician and surgeon, providing emergency
    medical services in any department of those
    hospitals to a person at the hospital

  • shall not be civilly or criminally liable for
    detaining a person who is subject to detention
    pursuant to Section 5150 of the Welfare and
    Institutions Code, if all of the following
    conditions exist during the detention

  • (1) The person cannot be safely released from the
    hospital because, in the opinion of the treating
    physician and surgeon, or a clinical psychologist
    with the medical staff privileges, clinical
    privileges, or professional responsibilities
    provided in Section 1316.5, the person, as a
    result of a mental disorder, presents a danger to
    himself or herself, or others, or is gravely
    disabled. For purposes of this paragraph,
    "gravely disabled" means an inability to provide
    for his or her basic personal needs for food,
    clothing, or shelter.

  • (2) The hospital staff, treating physician and
    surgeon, or appropriate licensed mental health
    professional, have made, and documented, repeated
    unsuccessful efforts to find appropriate mental
    health treatment for the person.
  • (3) The person is not detained beyond 24 hours.
  • (4) There is probable cause for the detention.

  • 5) If the person is detained beyond eight hours,
    but less than 24 hours, all of the following
    additional conditions shall be met

  • (A) A transfer for appropriate mental health
    treatment for the person has been delayed because
    of the need for continuous and ongoing care,
    observation, or treatment that the hospital is
  • (B) In the opinion of the treating physician and
    surgeon, or a clinical psychologist with the
    medical staff privileges or professional
    responsibilities provided for in Section 1316.5,
    the person, as a result of a mental disorder, is
    still a danger to himself or herself, or others,
    or is gravely disabled, as defined in paragraph
    (1) of subdivision (a).

  • Subsection (d) specifically states that the time
    detained, up to 24 hours, shall be credited
    against the subsequent 5150 (72 hr) hold

SB 1606 - Yee (Lauras Law)
  • An act to amend Lauras Law to make
    implementation easier (as originally proposed)
  • Introduced February 22, 2008 read first time on
    February 25, drastically amended April 3, heard
    on April 15, re-referred to committee on April
    16, next hearing set for Monday, April 28.

Tarasoff Warnings
  • Psychotherapist has a duty to warn when client
    communicates (even through a family member) a
    serious threat of harm against a reasonably
    identifiable victim or victims
  • Civil Code 43.92 - no liability against
    psychotherapist if he/she makes reasonable
    efforts to communicate the threat to the victim
    or victims and to a law enforcement agency

WI Code 5328 Exceptions to Confidentiality
  • r) When the patient, in the opinion of his or her
    psychotherapist, presents a serious danger of
    violence to a reasonably foreseeable victim or
    victims, then any of the information or records
    specified in this section may be released to that
    person or persons and to law enforcement agencies
    as the psychotherapist determines is needed for
    the protection of that person or persons. For
    purposes of this subdivision, "psychotherapist"
    means anyone so defined within Section 1010 of
    the Evidence Code.

  • But, WI Code 5328 only applies to records
  • created in the course of providing services
  • Division 4 (commencing with Section 4000),
  • Division 4.1 (commencing with Section 4400),
  • Division 4.5 (commencing with Section 4500),
  • Division 5 (commencing with Section 5000),
  • Division 6 (commencing with Section 6000), or
  • Division 7 (commencing with Section 7100),
  • to either voluntary or involuntary recipients of
    services .

  • So, what about private pay, private practice

  • AB 1178 clarifies that private pay, private
    practice, psychotherapists who are covered by
    Civil Code 56.10 (and do not fall under the LPS
    Act confidentiality protections) may do Tarasoff
    warnings and that this would be an exception to
    their confidentiality rules, too!

Civil Code 56.10 - Confidentiality of Medical
Information Act or CoMIA
  • 56.10. (a) No provider of health care, health
    care service plan, or contractor shall disclose
    medical information regarding a patient of the
    provider of health care or an enrollee or
    subscriber of a health care service plan without
    first obtaining an authorization, except as
    provided in subdivision (b) or (c).

New subsection
  • (c)(19) The information may be disclosed,
    consistent with applicable law and standards of
    ethical conduct, by a psychotherapist, as defined
    in Section 1010 of the Evidence Code, if the
    psychotherapist, in good faith, believes the
    disclosure is necessary to prevent or lessen a
    serious and imminent threat to the health or
    safety of a reasonably foreseeable victim or
    victims, and the disclosure is made to a person
    or persons reasonably able to prevent or lessen
    the threat, including the target of the threat.

  • Old law
  • Civil Code 56.10 (b)disclosures shall be
    made(9) When otherwise specifically required by

Adverse Event Reporting
  • 1998 IOM report
  • Leapfrog Group - 28 never events
  • July 1, 2007 - reporting of specific adverse
    events must be reported by hospitals to their
    local California Department of Health Services
    Licensing and Certification Office
  • Deficit Reduction Act

Preventable Errors/HACs
  • As of October 1, 2008 CMS will no longer pay for
    certain preventable errors and Hospital
    Acquired Conditions
  • Many other health insurance companies are
    following that lead (the Blues, CIGNA, etc.) and
    sending letters to hospital administrators
    asking them not to bill them, or their members,
    for certain adverse events

  • February 2008 - the AHA sent a letter to its
    hospital members asking them to voluntarily adopt
    a no-charge policy for serious adverse events
    (never events)
  • Crucial that medical staff charts POA (present
    on admission)

HACs include
  • Object left in during surgery
  • Air embolism
  • Blood incompatibility
  • Catheter-associated urinary tract infection
  • Pressure ulcers (bed sores)
  • Vascular-catheter-associated infection
  • Surgical site infection (specifically
    mediastinitis after coronary artery bypass
    grafting surgery - CABG)
  • Hospital-acquired injury due to external causes
    such as falls crushing injury, burns , etc.

Joint Commission publication
  • Cultural Sensitivity A Pocket Guide for Health
    Care Professionals
  • www. jcrinc.com
  • gt Publications
  • gtgt search Cultural Sensitivity
  • (35 for 5 booklets)

Tort Reform News on the MICRA Front
  • Anthony D. Lauria, Esq.
  • Lauria Tokunaga Gates Linn, LLP
  • 1000 a.m. - 1030 a.m.

(No Transcript)
  • THE CRISIS In the early 1970s, a medical
    malpractice insurance crisis gripped California.
    Liability premiums soared more than 300 percent
    because of more frequent and severe liability
    claims and larger malpractice jury awards. Many
    physicians particularly in high-risk
    specialties such as obstetrics and neurosurgery
    were forced to close their doors, either unable
    to get insurance or unable to afford inflated
    rates. Denied access to affordable care,
    California patients suffered. In 1975, Governor
    Jerry Brown called a special session of the
    California Legislature to solve the "malpractice

(No Transcript)
Pre-MICRA Problems
  • California in the early 70s saw a dramatic
    increase in number and size of malpractice
  • As a result malpractice insurance companies had
    huge underwriting losses, and raised their
    premiums anywhere between 300 and 500 other
    insurance companies just left the state
  • One survey showed that more than half of the
    doctors planned to reduce or entirely stop
    providing services to California residents

MICRA protects patients' access to
  • Acupuncturists
  • Chiropractors
  • Clinical laboratory technicians
  • Dentists
  • Dietitians
  • Hearing aid dispensers
  • Hygienists
  • Licensed Midwives
  • Marriage and Family Therapists
  • Nurse Anesthetists
  • Nurse Practitioners
  • Nurses
  • Occupational Therapists
  • Opticians
  • Optometrists
  • Perfusionists
  • Pharmacists
  • Physical Therapists
  • Physician Assistants
  • Physicians
  • Psychiatrists
  • Psychologists
  • Research Psychoanalysts
  • Social Workers
  • Speech-Language Pathologists and Audiologists
  • Telephone Medical Advice Services
  • Veterinarians

Provisions of MICRA
  • 1. Limits on Non-Economic Damages Non-economic
    damages in a claim against a health care provider
    for medical negligence are limited to 250,000.
    Economic damages, such as lost earnings, medical
    care, and rehabilitation costs, are not limited
    by statute. California Civil Code Section 3333.2.
  • 2. Evidence of Collateral Source Payments  A
    defendant in a medical liability action may
    introduce evidence of collateral source payments
    (such as from personal health insurance) as they
    relate to damages sought by the claimant. If a
    defendant introduces such evidence, the claimant
    may also introduce evidence of the cost of the
    premiums for such personal insurance. Civil Code
    Section 3333.1.

Provisions of MICRA
  • 3. Limits on Attorney Contingency Fees In an
    action against a health care provider for
    professional negligence, an attorneys
    contingency fee is limited to 40 of the first
    50,000 recovered 33 and 1/3 of the next
    50,000 25 of the next 500,000, and 15 of any
    amount exceeding 600,000. California Business
    and Professions Code Section 6146.
  • 4. Advance Notice of a Claim To further the
    public policy of resolving meritorious claims
    outside of the court system, MICRA requires a
    claimant to give a 90-day notice of an intention
    to bring a suit for alleged professional
    negligence. If the notice is given within 90 days
    of the expiration of the statute of limitations,
    the statute is extended 90 days from the date of
    the notice. California Code of Civil Procedure
    Sections 364 and 365

Provisions of MICRA
  • 5. Statute of Limitations  In California, a claim
    for alleged medical negligence must be brought
    within one year from the discovery of an injury
    and its negligent cause, or within three years
    from injury. Code of Civil Procedure Section
  • 6. Periodic Payments of Future Damages A health
    care professional may elect to pay a claimants
    future economic damages, if over 50,000, in
    periodic amounts. This avoids a claimants
    wasting of an award prior to actual need. Code of
    Civil Procedure Section 667.7.

Provisions of MICRA
  • 7. Binding Arbitration of Disputes Patients and
    their health care providers may agree that any
    future dispute may be resolved through binding
    arbitration. California statute requires specific
    language for such contracts and also provides
    that all such contracts be revocable within 30
    days. Code of Civil Procedure Section 1295.

Impact of MICRA
Insurance Information Institute 2003
Impact of MICRA
Lower Median Awards
Effects of MICRA Insurance Information
Institute 003
  • A General Accounting Office report on medical
    malpractice published in December 1986 singled
    out the reforms enacted in California as among
    the most effective in moderating increases in the
    cost of insurance and the size of awards.
    According to Jury Verdict Research data, the
    median jury award in medical malpractice
    litigation in California in the period 1997 to
    2002 is 402,500, significantly lower than other
    states with no reforms. It compares with an award
    median for the period 1996 to 2001 of 1 million
    in New York, 806,750 in Florida and 840,000 in
    Pennsylvania, for example (Exhibit 12).

Effects of MICRA -continued Insurance Information
Institute 003
  • In addition, the frequency of million dollar plus
    medical malpractice awards in California is
    considerably lower than in other states (Exhibit
    13). Californias doctors also pay significantly
    less for their liability insurance than their
    colleagues in other states. The AMA reports that
    since 1976, medical liability premiums across the
    US have increased three times faster than in
    California. It puts the savings to Californians
    at more than 1 billion a year. According to the
    HHS, states with limits of 250,000 or 350,000
    on noneconomic damages experienced an average
    premium increase of just 12 percent to 15 percent
    in 2001, compared with a 44 percent increase for
    states with no caps on noneconomic damages.

How successful has MICRA been?
  • At the height of Californias medical liability
    crisis, insurance premiums for anesthesiologists
    reached 22,702 per year. Current rates are
    10,337 per year 50 below the rates charged in
  • (Norcal Mutual Insurance Company, January 31,
  • Since MICRA was enacted 27 years ago, medical
    liability premiums in CA have risen just 167
    compared to 505 for the rest of the nation.
  • (Physician Insurers Association of America)

Where we are going?
  • In 1998 there was a huge effort to reform MICRA
    (especially the cap on pain and suffering) --
  • A study by LECB, Inc. concluded that there were
    as many claims in 1998 as before enactment of
    MICRA and that adjusted for inflation, the
    medically injured received higher compensation
    after MICRA than before
  • There has been talk of other attempts to change
    MICRA -- especially CAP on damages and attorneys
    fees-- Currently, no pending or threatened


Falls, Wandering, Elopements and Patients Who
Leave AMA
  • Linda J. Garrett, JD Risk Management Services
  • 1045 a.m. - 1130 a.m.

Quick review
  • Consent
  • Informed Consent
  • Capacity
  • The Right to Refuse Care
  • Restraints

Patient rights
  • People have the right of self-determination over
    their bodies and property.
  • People have a right to consent to medical care
    and to refuse care.
  • Individuals who are unable to exercise this
    right, have the right to be represented by
    another person who will speak on their behalf.

  • Patients have right to be free from restraints
  • Restraints for medical purposes
  • Restraints for behavioral purposes

Medical consent
  • Should be informed
  • Should be understood (language and level of
  • Should be voluntary

Chart capacity if it is lacking
  • What is the nature of the Lack of Capacity?
    (unconscious? psychotic? drunk? minor?)
  • Who will be the surrogate decision maker who will
    act on behalf of the patient?

  • Joint Commission National Patient Safety Goals
  • gt 2006 goal reducing harm due to patient
  • gt Implement a falls reduction program and
  • conduct ongoing assessment of the
  • of the program.

  • CMS
  • requires facilities to provide care within a safe
  • gt after October 2008, no reimbursement for 8
    hospital acquired preventable conditions which
    include falls

Fall facts (ECRI Institute)
  • 1.6 million falls reported each year
  • 10 in acute setting (30 of those result in
    serious injury)
  • Most common injury is hip fracture (24 die
    within 1 year, 50 never return to normal level
    of functioning) after hip fx, risk of falling
    again increases

  • Falls cost acute care facilities over 1 billion
    in 2002 (to treat the 30 of serious injuries)
  • Insurance claims average 70K
  • 2002 Alabama verdict - 7 M

What are the risks for our patients/residents?
  • Intrinsic (patient specific) risk factors
  • (physical, mental, cognitive)
  • Age greater than 65
  • History of falls
  • Incontinence, urinary frequency or urgency
  • Lower-extremity weakness
  • Gait and balance deficits
  • Medications (esp. sedatives, antihypertensive,
    tranquillizers, etc, or more than 4 prescription
    drugs at a time)

  • Postural or orthostatic hypertension
  • Reduced visual acuity/slowing darkness
    adaptation/ depth perception/contrast sensitivity
  • Loss of hearing
  • Neuropathy
  • Proprioceptive dysfunction
  • Cervical degenerative disorders
  • Functional impairment
  • Changes to mental status (depression, dementia)

  • Foot disorders
  • Poor impulse control
  • Belief that asking for help is inappropriate
  • Other things too!

Extrinsic (environmental) risk factors
  • Dangerous bathrooms (e.g., no rails near toilet)
  • Furniture on wheels or furniture with sharp edges
  • Flooring that is slippery or covered with loose
  • Ill-fitting shoes, or shoes with soles that stick
  • Poorly maintained equipment
  • Poor instruction on use of assistive devices
  • Time of day (shift change, less staff at night)
  • Bed too high toilet too low

  • Use of restraints full length bed rails
  • Colors that are monochromatic or that agitate
  • Distracting noises
  • Poor communication
  • Poor staff training
  • Attachment to equipment such as monitors
  • Call button too far side table too cluttered

Strategies to reduce falls
  • Policies and procedures
  • include definition of fall and near miss
  • Patient assessment at time of admission and
    periodically throughout stay
  • Environmental assessment
  • Frequent toileting (recent study shows 50 of
    falls related to toileting needs)
  • Reduce use of restraints, bed rail hazards

  • Adequate staffing is crucial and staff must
    communicate risk of falls with patient, family
    and each other
  • Identify at-risk patients at admission and during
    stay medication review

  • Train everyone! (patients, family, staff,
    students, volunteers)

Wandering and Elopements
  • Wandering off the unit or out of a facility is
    the 4th most common adverse event in Long Term
    Care (Gurwitz, JH, et al, J of American Geriatric
    Society 42(1)33-8)

  • Potential for significant harm
  • e.g., 1/5/08 48 year old patient found dead on
    Detroit street, frozen, dressed only in a
    hospital gown, t-shirt and boxer shorts
  • 2005 case settled for 750,000 involving 83 y/o
    woman who suffered fatal head injuries in fall
    she sustained while wandering away from PA
    nursing home

Policies, procedures, drills and training are
  • Identify who is at risk (what are the intrinsic
    and extrinsic factors?)
  • Diagnoses such as dementia, Alzheimers,
    psychiatric illnesses
  • Prior history
  • Stated desire to leave
  • Higher risk when first admitted, at shift change,
    during storm or inclement weather

  • Factors, continued
  • Boredom
  • Personal problems - depression, agitation

  • Camouflage enclosures (hide doors so they dont
    look like doors)
  • Enhance signage and clues for finding way back to
  • Enclose outdoor spaces
  • Assign rooms away from high traffic or noise
  • Create wandering path or space

  • Elvis has left the building codes
  • Clothing - ask family to bring only one color of
    clothing (e.g. blue) for resident so staff are
    alerted when person in blue is near a door
  • Reassessment when there is a just in time

  • Resident-worn transmitters/door alarms (help
    identify those who are potential exit-seekers)
  • Window restrictors as allowed by fire code
  • Video surveillance
  • Security guards

Finding lost patients
  • Remember, patients with dementia
  • dont ask for help
  • dont respond to shouts,
  • dont travel far,
  • leave few physical clues,
  • lack the ability to turn around.

  • Canadian study
  • Searchers should be as quiet as possible so they
    dont scare person
  • Person may hide in a closet

Things that help searchers
  • Personal items for scent - every six months
    change items in zip lock bags (use gloves) with
    residents name so search and rescue animals can
    have fresh scent
  • Physical description on all residents (pre-typed)
    and recent photo
  • Copy of residents shoe treads

  • GPS devices in clothing
  • Alzheimer's Safe Return Program - ID bracelet
    with toll-free number
  • Adequate supply of flashlights for night search
  • If you cant find in 15 minutes, call police!

Leaving the Hospital Against Medical Advice or
  • Patients have the right to..
  • Leave the hospital even against the advice of

Recommended procedure
  • Notify physician immediately
  • Try to delay patient until he/she can speak with

  • If patient leaves before MD has an opportunity to
    discuss situation
  • attempt to get patient to sign AMA form (see
  • when appropriate, notify Administration, Risk
    Manager and/or other staff physician

  • Physician should discuss the request with the
    patient either by phone or in person, if
    possible, and try to dissuade patient from
  • Information provided should include potential
    consequences of leaving, benefits of staying, and

  • If appropriate (and with authorization to share
    protected health information from patient)
    consider involving family, clergy or friends

  • Consider capacity issue
  • Get help from ethics committee if appropriate
    (e.g., when leaving means withdrawing
    life-sustaining treatment)
  • If leaving will have serious consequences to
    patient always notify administration and risk

  • Carefully chart informed refusal (patient
    warned of consequences of leaving hospital in
    unstable condition patient advised to call
    physician immediately if . and to return to
    nearest hospital ED if .)
  • Make a copy of discharge instructions

  • Take steps to ensure that the patient leaves in a
    safe manner, e.g., escort to the exit in a wheel
    chair, make arrangements so patient doesnt drive
    and endanger third parties (e.g., call a taxi or
    family member)

EMTALA Patient
  • have patient sign
  • EMTALA Patient Request for Transfer or
    Discharge form, and/or
  • Patient Refusal of Transfer form (See

  • If patient refuses to sign form, fill out form
    and note on form that patient has been warned of
    consequences but refuses to sign form have
    witness sign form
  • If patient has left without telling nurse, chart
    last time seen, and circumstances notify
    physician immediately

Other issues that you may have to consider
  • Call APS for help in getting conservator
    appointed if appropriate
  • If patient is a child, you may have to call CPS
    for intervention (medical neglect)
  • Homeless patients require extra care

Medication Error and
Prevention Regina Novello, RN, BSN, PHN Risk
Management Services 1130 a.m. - 1200 noon
(No Transcript)
Medication Error Defined
  • A medication error is any preventable event may
    cause or lead to inappropriate medication use or
    patient harm while the medication is in control
    of the health care professional, patient or

Medication Errors
  • Medication errors are one of the
  • leading causes of injury to hospital
  • patients.
  • Over half of all hospital medication
  • errors occur at the interfaces of
  • care.

  • Poor communication of
  • medical information at transition
  • points is responsible for as many
  • as 50 percent of all medication
  • errors and 20 percent of adverse
  • events.
  • Medication history, in most cases,
  • has no clear standardized
  • process.

How can Medication Errors Be Prevented? I Take
a Blue Pill
If a Patient Cannot Remember Their Medications
  • Obtain a detailed description of the
  • medication from the patient or family
  • member strength, size, shape, color,
  • markings.
  • Talk to any family members present.
  • Contact someone who could possibly
  • bring in the medication or read it over
  • the phone.

  • Try calling the patients pharmacy to
  • obtain a list of medication(s) the
  • patient has been currently prescribed.
  • Contact the patients physician(s) and
  • try and get an accurate listing of
  • current medications.

Medication Reconciliation I
  • Defined as a formal process of obtaining a
    complete and accurate list of each patients
    current home medication including name, dosage,
    frequency and route.
  • Compare to the physicians admission, transfer,
    and/or discharge orders. If there are any
    discrepancies, bring them to the attention of the

Remember to ask about any over the counter
medications, herbal medications, or medications
that may have been purchased outside the country.
Medication Reconciliation II
  • There are three steps to this process
  • Verification collect the medical history
  • Clarification make sure the medication and
    dosages are correct
  • Reconciliation document any changes in the order

Best Practice Blanket Orders
Prohibit the use of Blanket orders!
  • For example, do not accept
  • Continue previous medications
  • Resume preoperative medications
  • Continue orders from med/surg unit
  • Discharge on current medications

  • Any order previously written, should
    be re-written in its entirety

Best Practice Faxed Orders
  • Order forms and prescriptions should have margin
    lines to indicate where writing is not
  • Avoid fax orders if possible electronic
    transfer is preferred where available.

  • Print all orders for improved legibility.
  • Never cross out or overwrite a mistake! The
    order must be rewritten

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Best Practice High Alert Medications
High alert medications increase the risk
significantly for a bad patient outcome,
including death.
  • Examples
  • Chemo agents IV Heparin
  • IV and SQ Insulin TPN etc
  • IV Thrombolytics
  • IV Potassium Chloride

Reduce the Risk of High Alert Medications
  • Each Hospital should have a standardized list of
    High Alert medications.
  • Each Hospital must have a written policy
    regarding the administration of these medications.

  • Reduce the risk by limiting access to these
  • medications.
  • Use auxiliary labels
  • Standardize the ordering
  • Have the pharmacist, when possible, be
    responsible for the mixing of these medications.
  • Employ double checks.

Best Practice Documentation

Best Practice for Documentation
Includes Leading or Trailing Zeros
Do Not Use Trailing Zeros
  • Never trail a zero after a decimal point
  • (1.0 mg may be mistaken for 10 mg if the
    decimal point is not seen.)

Use a Zero Before a Decimal Point For example
0.5 mg verses .5 mg (.5 mg may be mistaken for
5 mg if the decimal point is not seen).
Make sure there is adequate space between the
drug name and the dosage
  • This is especially important in medications
    ending in the letter l where the letter may
    be mistaken for the number one.
  • For Example Inderal40 mg
  • vs.
  • Inderal 40 mg

Make sure there are properly placed commas
  • For Example
  • 100000 may be mistaken for 10,000.
  • Best Practice Always use a comma or
  • write out thousand, or 10 thousand, or 100
  • thousand.

Best Practice for Look Alike or Sound Alike
  • Determine the purpose of the medication before
    dispensing or administering medications. Most,
    not all, look alike or sound alike drugs are for
    a different purpose, for example Clonidine verse
  • Develop a policy for look and sound alike
  • Review with medical staff annually to raise
  • Do not keep these Alike medications in the same

Navane or Norvasc
Coumadin or Avandia
Best Practice for Look Alike or Sound Alike
  • Accept verbal or telephone orders only when
  • Always read back the orders, spell the name of
    the medication and state its intended use.
  • Use preprinted orders when appropriate to
    minimize the chance of error.

Best Practice Verbal Orders
  • Try to avoid verbal orders
  • Do not accept verbal orders for chemo
  • Have the lab work done before physician rounds
    to avoid over the phone dosage changes.
  • The order should make sense, if it doesnt, then
    it probably isnt right
  • Record the order directly onto the order sheet
    to eliminate another chance for error.

  • Receiver should sign, date, and time the order
  • The prescriber must verify, sign, date the order
    within a predetermined time frame based on the
    facilities Policy and Procedure.
  • Allow no verbal orders when the physician is
  • Limit verbal orders to formulary drugs
  • Spell back the drug name and repeat all orders
    back to the prescriber.

Best Practice Approved and Do Not Use
Abbreviations List
  • Create a list of confusing abbreviations that
    staff should NOT use due to potential for error
    and misinterpretation.
  • Create a list of approved abbreviations
  • general,
  • laboratory,
  • obstetrics,
  • physical therapy
  • surgical.

Here are a few abbreviations to avoid
  • Intended Meaning Hour(s), i.e. q1º
  • Misinterpretation Mistaken for a zero when
    handwritten. i.e. every 10
  • Correction Hr

  • Intended Meaning Magnesium Sulfate
  • Misinterpretation Mistaken for Morphine
    Sulfate (MSO4)
  • Correction Write out magnesium

  • Intended Meaning Morphine Sulfate
  • Misinterpretation Mistaken for
    Magnesium Sulfate (MgSO4)
  • Correction Write out morphine

ug or µg
  • Intended Meaning Micrograms
  • Misinterpretation Mistaken for mg when
    handwritten because u looks like m
  • Correction mcg

  • Intended Meaning Subcutaneous
  • Misinterpretation The q has been mistaken for
  • Correction SQ

  • Intended Meaning Inch
  • Misinterpretation Mistaken for 11
  • Correction Write out inch

Best Practice Always Practice the Six Rights
  • Right Patient
  • Right Medication
  • Right Dose
  • Right Route
  • Right Frequency
  • Right Documentation

Best Practice
  • Always take the MAR (Medication Administration
    Record) or chart with you to the patients
    bedside or into treatment room
  • Compare medication to the MAR or chart at the
    bedside or chairside.

  • Medication safety practices are everyones
  • Involve the medical staff at their meetings
  • Have staff approve policies to gain their
  • buy in
  • Bring administration to the table on safety and
    quality issues to raise awareness and send the
    message of its importance.

  • Lunch
  • (back at 100 p.m.)

Correctional Care Issues
  • Linda Garrett, JD
  • Risk Management Services
  • 100 p.m. - 130 p.m.

Jail healthcare responsibility
  • Title 15 Regulations and Guidelines are clear
    that the facility administrator (sheriff) is
    responsible for housing inmates and that part of
    this responsibility includes providing for
    necessary medical, dental and mental health care
    while the person is in the jail (15 CCR , section
  • There is considerable leeway in how those
    services will be provided

Where can services be provided?
  • Outside facilities (all services)
  • Only first aid at jail everything else goes out
  • Only emergencies go out (911) all other services
    at jail
  • All services are provided at jail

Who can provide jail healthcare services?
  • Employed health care providers who work as
    employees of the sheriffs department or
  • Contracted local hospital, private doctor,
    psychiatrist, medical group, correctional
    healthcare company (e.g., CFMG, PHS), medical
  • County health department and/or mental health
  • Regional agreement among counties to have roving
    doctors and support personnel

Pre-booking medical care
  • Prior to going to the jail, law enforcement will
    take individual to hospital for obvious medical
    needs and/or DUI testing
  • Sometimes person will ask to go to hospital for
    non-obvious medical needs
  • Sometimes jail medical personnel will refuse the
    individual and ask law enforcement to get the
    person medically cleared at a local hospital

Who pays for pre-booking care?
  • If the person is seen at the hospital ED prior to
    being booked into the jail, the individual is
    responsible for his/her medical costs (private
    pay or insurance, including MediCal/Medicare) NOT
    the sheriff!

Penal Code 4015
  • (a) (the board of supervisors shall provide the
    sheriff with necessary food, clothing, and
    bedding, for prisoners which meets minimum
    standards and requirements prescribed by Board of
    Corrections for feeding, clothing, and the care
    of prisoners)

  • (b) Nothing in this section shall be construed in
    a manner that would require the sheriff to
    receive a person who is in need of immediate
    medical care until the person has been
    transported to a hospital or medical facility so
    that his or her medical needs can be addressed
    prior to booking into county jail.

  • (c) Nothing in this section shall be construed or
    interpreted in a manner that would impose upon a
    city or its law enforcement agency any obligation
    to pay the cost of medical services rendered to
    any individual in need of immediate medical care
    who has been arrested by city law enforcement
    personnel and transported to a hospital or
    medical facility prior to being delivered to and
    received at the county jail or other detention
    facility for booking.

  • (d) It is the intent of the Legislature in
    enacting the act adding this subdivision to
    ensure that the costs associated with providing
    medical care to an arrested person are borne by
    the arrested persons private medical insurance
    or any other source of medical cost coverage for
    which the arrested person is eligible.

  • (This section of the Penal Code was amended to
    read this way by a bill sponsored by the state
    Sheriffs Association after an AG opinion --
    90-911 filed on January 31, 1991 -- concluded the
    sheriff was responsible)

DHS Letter 93-42
  • July 7, 1993
  • Person is ineligible for Medi-Cal from the time
    that the person actually becomes an inmate until
    he is released, paroled, or on probation
  • But, any other time he is eligible!

Person is eligible for Medi-Cal
  • 1. After arrest but before booking if escorted
    by police to a hospital for medical treatment
    and held under guard
  • 2. Person who transfers from jail temporarily
    to a halfway house or residential treatment
    facility prior to a formal probation release

  • 3. Released from jail on probation, parole, or
    release order with a condition of home arrest,
    work release, community service, outpatient
    treatment or inpatient treatment
  • 4. Released under a court probation order due
    to a medical emergency

  • 5. a minor in a juvenile detention center prior
  • disposition due to care, protection or in the
  • interest of the child if there is a specific
    plan for
  • that person that makes stay at the detention
  • center temporary (could include juveniles
  • awaiting placement but still physically present
  • the Hall)

  • 6. a minor placed on probation by a juvenile
    court on juvenile intensive probation with
    home arrest restrictions

  • 7. a minor placed on probation by a juvenile
    court on juvenile intensive probation to a
    secure treatment facility contracted with the
    juvenile detention center if the secure
    treatment facility is not part of the criminal
    justice system

  • 8. A minor placed on probation by a juvenile
    court on juvenile intensive probation with
    treatment as a condition of probation in a
    psychiatric hospital, resident treatment
    center, or as an outpatient

DHS Letter 94-02
  • January 5, 1994
  • Stated 1 year retroactive period for eligibility
    stated in clarifying guidelines on Medi-Cal
    eligibility of inmates of a public institution
    in letter 93-42

EMTALA duties of Hospitals
  • When a person (including an arrested person)
    comes to any hospital seeking medical care, the
    hospital must provide
  • 1) a medical screening examination to
  • 2) rule out any emergency medical condition,
  • 3) stabilize that condition if found, or
  • 4) transfer the patient to a hospital that can
    stabilize it if the first hospital cant

Sharp Healthcare v. County of San Diego (new
case law)
  • California Appellate Court held that counties are
    not responsible for the medical expenses of
    arrestees before they are booked
  • January 2008 - California Supreme Court denies
    petition for review of that case.

The future.
  • Sen. George Runner (R-Antelope Valley) is
    carrying state legislation related to this issue
    (CHA is advocating for fair payment for
    hospitals and wants sheriff to pay!)
  • See SB 1169 introduced February 7, 2008

  • Linda Garrett, JD
  • Risk Management Services
  • 130 p.m. - 230 p.m.

Substance abuse and mental health services
  • /http//www.coce.samhsa.gov
  • Link to COCE Resources

Why are we interested in integration of MH and
  • 1. Its better for the client
  • 2. Its better for the provider (us)

Better for the client
  • One stop shopping
  • Smooth coordination of care fewer interfaces
  • Collaboration amongst caregivers increased when
    they are on the same case managed treatment team
    - more continuity of care and less confusion

Benefits for client - continued
  • Improved client outcomes
  • Improved adherence to treatment plans where both
    interventions are supported (its easier to be

Better for the provider
  • Use less resources - people and money
  • If you dont treat the whole problem you have a
    lot of people you are trying to treat who arent
    getting much better

  • High community rates of COD California DMH study
    concluded that 50 of all Mental Health clients
    have Substance Abuse issues, and 50 of all
    Substance Abuse Clients have Mental Health Issues

  • Given high number of clients with COD seeking
    both services, makes sense to address COD in an
    integrated program since that is what the
    majority of your clients need

Benefits for the provider - continued
  • Improved adherence to treatment plans
  • Improved client outcomes
  • Less frustration for staff and
  • Increased job satisfaction

Benefits for provider -continued
  • Reduce need to shuffle between providers
  • Reduce need to make outside referrals
  • less likelihood of conflicting advice from
    several sources
  • better integration of information provided to

Dual dx or COD programs - more reasons they work
  • Studies show that there is a negative impact of
    one untreated disorder on recovery from the other
  • Studies also show that effective responses to
    persons who need treatment for either mental
    health or substance abuse disorder are compatible
  • Successful when dealing with severe disorders as
    well as less severe disorders

Single Agency Approach
  • More efficient (reduces staff and saves money)
  • You only need
  • One HR department
  • One billing office
  • One admissions office
  • One healthcare risk manager

Agency approach - continued
  • One compliance office
  • One HIPAA Privacy Official
  • One records department
  • One IT department
  • One financial office
  • Same maintenance and housekeeping
  • Etc., etc., etc.

So, whats the problem?
  • If it is good for the clients and good for the
    County why are we even discussing this?
  • Why not just go ahead and combine the various
    medical and mental health and substance abuse
    services in one big program and leave it at that?

  • The problem is this -- treating COD at the same
    time is a rather new concept -- only in the last
    10-15 years has this approach become an accepted
    way to approach COD and all of the laws,
    particularly the confidentiality laws, were
    written with the old model in mind.

  • There is a wall between the disciplines that
    makes disclosures between providers impossible
    unless certain steps are taken -- the wall is
    known as 42 CFR Part 2

An illustration of the problem
  • Lets look at an example from somewhere else in
    the County
  • Why not put all of the attorneys that are on the
    Countys payroll into one Agency and call it the
    Legal Agency and have them share support staff,
    records rooms, IT, computers, reception, HR,
  • Confidentiality (and conflict) is why!

  • Medical confidentiality laws put similar barriers
    between the various disciplines -- even though
    they are all healthcare providers, that doesnt
    necessarily mean they can all sit down and talk
    to each other about their patients and clients

Review of confidentiality laws
  • Civil Code 56.10
  • WI Code 5328
  • 42 CFR Part 2
  • HIPAA (45 CFR Part 160, 164)

Sharing with other providers
  • General health info may be shared with other
    healthcare professionals for purposes of
    treatment, diagnosis or referral
  • Civil Code 56.10(c) (1)

  • Mental health info may be shared in
    communications between qualified professional
    persons in the provision of services or
    appropriate referrals, or in the course of
    conservatorship proceedings, including providers
    outside your program if they have medical or
    psychological responsibility for the client
  • WI Code 5328(a)

  • Substance abuse treatment program information can
    only be shared with members of the team within
    the program (not OUTSIDE the program see next
    slide for definition of program) EVEN though
    the program is within the same agency!
  • There is an exception for a medical emergency
    (e.g., overdose, or suicide attempt)

42 CFR section 2.11 - Definitions
  • Program means
  • (a) an individual or entity (other than a general
    medical care facility) who holds itself out as
    providing, and provides, alcohol or drug abuse
    diagnosis, treatment, or referral for treatment

  • (b) an identified unit within a general medical
    facility which holds itself out as providing, and
    provides, alcohol or drug abuse, dx, tx, or
    referral for tx or

  • (c) medical personnel or other staff in a general
    medical care facility whose primary function is
    the provision of alcohol or drug abuse dx, tx, or
    referral for tx and who are identified as such

42 CFR section 2.12(e)
  • Explanation of applicability. These regulations
    cover any information (including information on
    referral and intake) about alcohol and drug abuse
    patients obtained by a program ...However, these
    regulations would not apply, for example, to
    emergency room personnel who refer a patient to
    the ICU for an apparent overdose

  • Simply stated, a drug and alcohol treatment
    program is any defined program that receives
    state or federal funds to conduct drug and
    alcohol treatment
  • For example, the 8th floor of an acute care
    hospital where drug and alcohol treatment is

One alternative?
  • Some argue that they will subject the entire
    agency to the stricter rules, but because you
    will then be extremely limited in uses and
    disclosures that you have come to rely on in the
    Mental Health side (e.g., checking with the
    pharmacy, Tarasoff warnings, reporting elder
    abuse) it is really not the optimal way to
    approach this

Better alternative
  • Get permission (authorization) permitting members
    of the different clinical disciplines to work
    together within the County Agency

  • Note if you have a Human Services Agency that
    includes Social Services, Probation, etc. they
    would NOT be part of the authorization - separate
    authorizations would be needed for these types of

2 approaches
  • Every client who walks through the door receives
    the same NPP and signs an authorization before
    ANY servi
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