A 62-year-old man presented to the ED with depression and suicidal ideation.
He had a history of benzodiazepine addiction.
His family reported that he was stealing his daughter’s benzodiazepines as well.
The patient had a longstanding relationship with a local psychiatrist, but the ED doctor felt that his condition was too acute for discharge.
He was transferred to a psychiatric inpatient hospital on May 10.
His inpatient course was uneventful, and he was ready for discharge on May 19.
The inpatient psychiatrist wrote prescriptions for multiple medications:
The patient filled all of these prescriptions and began taking them.
On May 23, the patient reportedly woke up in the middle of the night and was delirious.
He tried to walk to the bathroom, but fell and broke his right hip.
He was taken back to the ED, admitted, and had a long rehab stay after surgery.
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The patient and his family filed a lawsuit against the inpatient psychiatrist.
An expert witness was hired and wrote the following opinion for the plaintiff:
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The defense responded that the patient’s own negligence played a key role in his injury:
The attorneys went to 2 mediation sessions and ultimately reached a confidential settlement.
MedMalReviewer Analysis:
Prescribing large amounts of benzodiazepines to this patient was a questionable decision, especially in light of his prior abuse of these medications. However, it appears that the psychiatrist was not completely aware of this history.
The plaintiff’s attorney focused specifically on the Ativan prescription, but I suspect that the combination of multiple medications was likely a key issue. Tramadol is independently associated with falls as well, and mixing opioids with benzodiazepines is often a recipe for disaster.
The expert witness opinion has some accurate criticism but also has some key facts wrong. The fall happened at the patient’s house, not in the hospital. Furthermore, the patient did have follow-up arranged with his outpatient psychiatrist. An appointment was scheduled less than 7 days after his discharge.
One of my key theories about medical malpractice is that these lawsuits are often driven forward by an angry family member, as opposed to the patient themselves. The wife in this lawsuit was very upset with both the patient (due to his addiction) and the psychiatrist. She felt that there was not good communication and that the medication issues and resulting fall would not have happened if she had been more involved. Obtaining collateral information is especially important in psychiatry, and can go a long way in reducing medicolegal risk.
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It would be incredible if insurance would reimburse for the extended time necessary to do ideal psychiatric work including time gathering collateral from family. Unfortunately procedures carry the day for physician payment. Insurance is paying for the services provided, and I think a theoretical liability should exist. Reimburse poorly don’t be surprised doctors have to rush through patients to earn a living.
Just want to make a note that contacting the outpatient psychiatrist while a patient is admitted to a psychiatric unit/facility is not the standard of care. Certainly it could be beneficial in some cases but not always--collateral information is often obtained through family, and at our facility we are provided the patient's past medical/psych history through the EMR, prescription monitoring programs, pharmacy dispense reports and other sources. This renders contacting the outpatient psychiatrist superfluous in most cases - ultimately as an inpatient psychiatrist we are (presumably) well-versed in managing high-risk cases and function in a multidisciplinary team to reduce risk and collaborate care. We provide updates to outpatient psychiatrists who are interested or by patient request (after an ROI is signed) but again, this is not a necessary step in terms of inpatient psychiatric treatment.