RISK MANAGEMENT IN THE CORRECTIONAL SETTING

1. RISK MANAGEMENTIN THECORRECTIONAL SETTING Jacqueline Moore President Moore and Associates February 2006

2. What is Risk Management? Risk management is the process of using policies, procedures, protocols and systems to reduce the likelihood of errors and/or adverse outcomes

3. Where might you see risk management being used?

4. Nuclear Power Industry • Most types of manufacturing • Automobile design • Surgery • Hospitals

5. RISK MANGAMENT DIAGRAM Egg Egg

6. ARREST DIVERT

7. ARREST DIVERT CUSTODY INTAKE SCREEN

8. ARREST DIVERT CUSTODY INTAKE SCREEN NURSING INTAKE SCREEN

9. ARREST DIVERT CUSTODY INTAKE SCREEN NURSING INTAKE SCREEN MEDICAL INTAKE SCREEN

10. ARREST DIVERT CUSTODY INTAKE SCREEN NURSING INTAKE SCREEN MEDICAL INTAKE SCREEN SICK CALL REQUEST SYSTEM

11. ARREST DIVERT CUSTODY INTAKE SCREEN NURSING INTAKE SCREEN MEDICAL INTAKE SCREEN SICK CALL REQUEST SYSTEM HOUSING SYSTEM

12. ARREST DIVERT CUSTODY INTAKE SCREEN NURSING INTAKE SCREEN MEDICAL INTAKE SCREEN SICK CALL REQUEST SYSTEM HOUSING SYSTEM CUSTODY OBSERVATION

13. ARREST DIVERT CUSTODY INTAKE SCREEN NURSING INTAKE SCREEN MEDICAL INTAKE SCREEN SICK CALL REQUEST SYSTEM HOUSING SYSTEM CUSTODY OBSERVATION CUSTODY AND HC COMMUNICATION

14. ARREST DIVERT CUSTODY INTAKE SCREEN NURSING INTAKE SCREEN MEDICAL INTAKE SCREEN SICK CALL REQUEST SYSTEM HOUSING SYSTEM CUSTODY OBSERVATION CUSTODY AND HC COMMUNICATION

15. Scenario OneBackground • 18 year old male who has been incarcerated for one month. Jail has 40 hour per week nursing and on call care after hours. • No medical problems noted at intake • One month later he complains of abdominal pain. States he has a history of umbilical hernia. • Nurse exam shows no sign of umbilical hernia. • What do you do next?

16. Physical Exam • PE revealed no protrusions re umbilical area • Abdomen non-tender • Bowel movements normal • Vital signs T 97.6, P96 skin warm and dry • Inmate unable to say where he had previously sought treatment • Inmate given Motrin

17. Next Day • Inmate back to clinic with complaints of abdominal pain and vomiting • There is no exam table in treatment room, patient requested to lie on floor • Palpation indicated negative McBurneys Sign

18. Four days later • Contacts nurse again in 4 days. Says pain is worse. • Mother contacts facility stating her son is in severe pain. • Nurse examines patient. No evidence of umbilical hernia. • What do you do next?

19. Patient complains of vomiting on day 5. Nurse examines patient. Documents no signs of umbilical hernia. Calls MD and gets order for phenergan which patient vomits up within 30 minutes. What do you do next? Day 5

20. Nurse visit. Patient still complaining of abdominal pain and sick to stomach. Nurse documents bowel sounds in all 4 quadrants. No rebound tenderness. No signs of umbilical hernia. What do you do next? Day 6

21. Day 7 • Custody staff report “spitting up brown stuff in cup”. Told by health care staff he's been checked and is OK.

22. Patient states “unable to pee”. UA shows ketones and slight WBC's. Physician called, orders CBC and blood sugar stat. WBC normal except slight left shift. Glucose normal. Nurse reports to MD white blood count normal but does not fax results. VS T 97.4, P 100, BP 116/66 R18. What do you do next? Day 8

23. Guards call nursing staff in the evening because patient still continues to complain of abdominal pain. Told that everything is all right. Nurse reports to officer that blood work is normal. What do you do next?

24. Officers do not check on inmate through the night. Custody calls nurse to find out when he's coming in? (Sat.) Tells nurse he needs to see patient that day. Officer reports that inmate has vomited coffee ground material. Nurse reports at noon. Patient collapses and dies. Noted to be “cold” by EMT's. Bloody vomit all over cell. What is the Diagnosis? Where would risk management have helped in this case? Day 9

25. Where is the Liability and with Whom?

26. Inconsistency in Care • EMS reports patient was expired on arrival • Nurse reports P 70 R12 • MD indicates she never saw copy of lab work • Nurse types nurse’s notes from home and adds them to the chart as late entry • Officers never started CPR • Nursing Protocol not followed

27. Conclusions • Cause of Death • Ruptured appendix with peritonitis • Deliberate indifference case filed • Providers careless and reckless and failed to comply with applicable standards of care • Case settled September 2005

28. Scenario 2Background • 17 year old white male adjudicated to juvenile academy on 12/28/98. Program has strong emphasis on sports. • April 5, 1999 following Easter Break youth returns to juvenile academy and is ill has symptoms of cough, chill, nasal stuffiness, diarrhea, upset stomach • Mother calls school to inform them of son’s illness • What would you do?

29. Juvenile Academy • Youth placed in infirmary • Treated by EMT with over the counter medicine • 4/7/99 Temperature reading is 104.3 at 6:40 AM • EMT puts cool compresses on youth’s forehead and provides OTC medicine

30. Temperature Chart4/7-4/8/99

31. 4/8/99 • Youth seen by school physician • Temperature100 degrees F at 8 AM • At 4:45 PM temperature 96.2 degrees F • Youth is disoriented, unable to provide MD with history of why he was present at sick call • MD orders patient to go to ER for evaluation

32. ER Fiasco • EMT notifies youths parents that youth is to go to the ER • EMT advised supervisor that youth is to be transported to ER • Youth refuses to go to ER states he feels better. Temperature 97.4 • Parents notified that youth does not want to go to the ER • Youth placed in infirmary. EMT tells officer to watch youth

33. Next MorningApril 9, 1999 • Youth disoriented • Officer moved youth out of infirmary • Youth fell to floor when getting out of bed • No vital signs were taken during the night • Youth urinated and defecated on himself • EMS called • Transferred to tertiary hospital craniotomy performed • Today patient suffers from speech and brain damage

34. What Went Wrong

35. What were the Problemswith this care? • Lack of Adequate Assessment • No notations of nuchal rigidity • Incomplete vital signs no pulse or BP (slowing of pulse indicative of increased intracranial pressure • No notations made re headaches, photophobia, irritability, malaise, change in LOC, chills or sudden changes in body temperature

36. Poor Monitoring of Temperature • Temperature readings over 102 degrees • No attempt to contact physician when temperature reached 104 degrees • Intermittent fever diurnal variations frequently seen in pyrogenic infections

37. Inadequate Charting • OTC medication given but we do not know drug, strength, frequency or how it affected temperature • Facility was unable to find medication log • Physician did not have access to medical record when he examined the patient

38. Inadequate Staffing and Training • Only two EMTs assigned to medical unit • No training in chronic or infectious diseases • No nursing oversight • EMTS frequently pulled to perform other assignments e.g. transport, assistance on field with sports etc. • No medical staff on the night shift

39. Failure to follow orders • MD assessed patient incapable of answering questions • Youth had altered medical status, with high fever, and upper respiratory infection • Supervisors of Academy made aware of transport order • No communication to MD that indicates youth not sent to ER • Customary practice of academy to cancel off-site appointments

40. Lack of Autonomy • Patient moved out of infirmary without notification of medical staff • No procedures in place of admission or discharge of youth to infirmary • Patient not monitored by night shift • Supervisors are in charge of medical unit

41. Failure to Communicate • Officer indicates EMT did not tell him to monitor patient • EMT indicates he told officer to monitor patient • Nothing recorded • No clear policy on communication between clinician and facility administration re medical needs of youth

42. Consent • EMT unaware of State Statute re informed consent • Supervisor did not clarify State Statute on consent for medical staff • What else could have been done? • Could parents have gone to the ER?

43. RISK MANGAMENT DIAGRAM Egg Arrest DIVERT INTAKE SCREEN NURSING SCREEN MEDICAL SCREEN MEDICATION SYSTEM SICK CALL REQUEST HOUSING OFFICER OBSERVATION CUSTODY/HC COMMUNICATION

44. Scenario 3 • Native American died of seizures in transport van. • He was in leg irons and belly chains when he arrived at the jail.

45. Background • Patient had been in jail several times previously • Known alcoholic • Previous charges were domestic violence • Current charge manslaughter • Had prior medical records indicating seizure • Had been brought to a mental health facility soon after arrest for a competency hearing

46. On the road to Mecca • Patient started breathing funny and shaking violently • Transport officers were present in major city • Hospital was two blocks away • Jail was two hours away • Officers called LPN who worked at small jail • What did she say to do?

47. Prior Medical History • Inmate was known to nurse, she indicated to officer that he had had seizures previously • Nurse advised officer to keep patient in upright position and if more than 3 seizures occurred in 20 minutes to seek medical assistance • Officer noted bubbly breath of inmate. • What should officers do?

48. Continuing Sega • Officer called other transport officer who was in the Federal Marshals Building • Inmate continued to have seizures-his arms and legs became tense, patient was described as unresponsive • What should the deputy do?

49. What did the Deputy Do? • He called the nurse a second time • He called the other transport officer urging him to hurry • Nurse called ER doctor indicating patient was having petit mal seizures • What is your assessment now?

50. Sega Continues • Officer calls nurse third time and asked if they should go to the hospital • Nurse assured Deputy that the inmate would be fine just monitor his breathing • Patient has another seizure • What should they do now?