Closed Claims—Open Insights: Managing Violent Behavior During Pediatric Care Insights to Reduce Risk and Improve Practice

Background

A 12-year-old patient with a history of autism and behavioral concerns presented to a pediatric practice with upper respiratory symptoms for seven days. After routine check-in protocols, the patient was initially evaluated by an Advanced Practice Provider (APP). The patient declined to have his ears examined and would not open his mouth for a throat evaluation. When the APP attempted an ear examination, the patient became agitated and struck the APP’s arm, knocking the otoscope away. Concern arose that further attempts at examination could lead to additional physical outbursts.

Allegations

• No formal claim was made by the patient, but allegations could have been made by the patient of failure to provide care due to the patient’s disability and violation of the Americans with Disabilities Act (ADA).
• No formal claim was made by the injured employee, but they also could file a claim alleging failure to maintain a safe environment for staff.

Case Review Insights

• Review revealed that this was an isolated occurrence of violent behavior in the office associated with an acute illness.
• It was unclear whether the APP had enlisted assistance from the child’s parent prior to initiating physical contact with the agitated patient.
• The supervising physician was also not aware of the child’s resistance to examination prior to the incident.

Resolution

The patient was referred to the emergency department (ED) for evaluation of his upper respiratory symptoms. The patient was not terminated from practice.

Lessons Learned

• Consider a patient’s history and behavior when conducting a visit.
• Always document violent incidents objectively in the record.
• Follow established policies and procedures for terminating a patient relationship and managing workplace violence.

Risk Management Tips

• Assess and document the patient’s behavior and how it may impact or limit evaluation in the office setting. Involve parents, patients, supervising physicians, and administration in formulating a safety plan for examination or in facilitating a referral to the emergency department.
• Document each incident of violence objectively to assist in determining whether a pattern of violence exists. Healthcare providers risk claims of discrimination if refusing care to patients with disabilities. The ADA allows a ‘direct threat’ defense only when objective evidence shows a significant risk of substantial harm.

• Develop and train staff annually on a policy for managing violent patients. Apply policies consistently to patients with and without disabilities, including the use of standardized termination letters when dismissing a patient from practice. Assign a designated provider to oversee decisions regarding violent patient scenarios for consistency.

Risk Management Resources

Curi Resources

If you have questions about this topic, please call 800-328-5532 to speak with one of Curi’s Risk Solutions Consultants, or consult the following:

• Risk Management Guide: Patient Dismissal
• Curi On Demand Webinar: Defusing the Angry Patient
• Curi Academy: Disruptive Patient Behavior – The Role of the Practice Manager

External Resources

• Americans with Disabilities Act Title II Regulations, Section 35.139 Direct threat. https://www.ada.gov/law-and-regs/regulations/title-ii-2010-regulations/
• US Department of Labor, Occupational Health and Safety Administration (OSHA), Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, https://www.osha.gov/healthcare/workplace-violence

Disclaimer

Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them.