How can I improve as an inpatient provider and minimize risk of patient harm and litigation?

How to Be a Better Inpatient Provider, Stay Out of the Courtroom, and Avoid Harming Patients

Focus on systematic identification and prevention of the eight nurse-sensitive factors that cause most preventable hospital harm: Skin integrity, Continence, Abnormal clinical findings, Nutrition, Deterioration in cognitive/mental state, Medications, Mobility, and Pain (mnemonic: "Have you SCAND MM Please?"). 1

Implement a Comprehensive Harm Prevention Framework

The most critical period for preventing harm is immediately upon admission, when patients are unfamiliar and risk assessment is most cognitively complex. 1 Begin harm prevention activities within the first hours of admission rather than waiting, as delays in implementing preventive measures directly correlate with adverse outcomes. 1

Priority Risk Assessment on Every Patient

Rapidly screen every admitted patient for vulnerability across all eight harm factors simultaneously rather than using separate, duplicative assessment tools for each risk. 1 This integrated approach reduces documentation burden while improving safety outcomes. 1

• Skin integrity: Assess for pressure ulcer risk and implement pressure-relieving bedding materials immediately for high-risk patients 2
• Continence: Evaluate bladder and bowel function to prevent complications and maintain dignity 1
• Abnormal clinical findings: Monitor vital signs and pulse oximetry continuously, with particular attention to oxygen saturation <95% on room air as a critical threshold requiring escalation 1, 3
• Nutrition: Provide early enteral nutrition in critically ill and surgical patients, as appropriate nutrition provision is among the strongest evidence-based safety practices 2
• Deterioration in cognitive/mental state: Screen for delirium, cognitive impairment, and mental status changes at admission and throughout hospitalization 1
• Medications: Conduct thorough medication reconciliation with inpatient pharmacist involvement before discharge 1
• Mobility: Assess fall risk and implement prevention strategies, as patient falls represent a major category of preventable harm 1
• Pain: Systematically assess and manage pain to prevent complications and improve outcomes 1

Medication Safety: The Highest-Risk Area

Adverse drug events account for 39% of all adverse events in hospitalized patients, making this your single highest-risk area. 4

Critical Medication Practices

• Use maximum sterile barriers during central line placement to prevent catheter-related infections, which is among the most strongly evidence-supported safety practices 2
• Implement continuous aspiration of subglottic secretions (CASS) in ventilated patients to prevent ventilator-associated pneumonia 2
• Consider antibiotic-impregnated central venous catheters to reduce infection risk 2
• Use real-time ultrasound guidance for all central line insertions to prevent mechanical complications 2
• Ensure inpatient pharmacist counseling before every discharge, particularly for patients on corticosteroid tapers or complex medication regimens, as this demonstrably reduces rehospitalization 1

Antibiotic Stewardship to Avoid Litigation

When prescribing antibiotics, use appropriate prophylaxis according to established guidelines rather than empiric broad-spectrum coverage without indication. 1 For surgical patients, appropriate antibiotic prophylaxis prevents postoperative infections and represents high-quality evidence for harm reduction. 2

Discharge Planning: Where Most Lawsuits Originate

Ensure clinical stability for 24-48 hours before discharge with normalized vital signs and oxygen saturation, as premature discharge is a major source of preventable harm and litigation. 1, 3, 5

Mandatory Pre-Discharge Requirements

• Psychiatric evaluation is mandatory before hospital discharge in all cases, not just psychiatric patients 5
• Screen for mental health, substance use disorders, and social care needs before any discharge decision 1, 5
• Conduct medication reconciliation and patient counseling by inpatient pharmacist to ensure adherence and prevent adverse drug events post-discharge 1
• Schedule outpatient follow-up within 48 hours before the patient leaves the hospital, not after 1, 3, 5
• Assign patient navigators for those with barriers to care, and implement telephone or text check-ins to ensure stability 3

Specific High-Risk Discharge Scenarios

For patients on corticosteroids, evaluate for risk of secondary adrenal insufficiency and counsel about symptoms (fatigue, decreased appetite, gastrointestinal distress, myalgia, joint pain, salt craving, dizziness, postural hypotension). 1 Consider endocrinology follow-up for prolonged courses. 1

For psychiatric patients, verify the discharge environment has sufficient support and someone who can take action if the patient's condition deteriorates. 5 Never discharge without the caretaker being present for discharge planning and verifying the patient's account. 5

Venous Thromboembolism Prophylaxis: Non-Negotiable

Use appropriate prophylaxis to prevent venous thromboembolism in all at-risk patients, as this represents the strongest evidence-based safety practice with clear mortality benefit. 2 Failure to provide VTE prophylaxis is indefensible in litigation.

Surgical and Procedural Safety

• Use perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality 2
• Implement appropriate surgical antibiotic prophylaxis according to guidelines 2
• Ask patients to recall and restate information during informed consent to ensure comprehension, as this active confirmation process is evidence-based for reducing consent-related litigation 2

Infection Prevention

Healthcare-associated infections account for 11.9% of adverse events. 4 Beyond central line precautions:

• Use maximum sterile barriers for central line placement 2
• Implement infection prevention protocols systematically rather than selectively 1
• Monitor for multidrug-resistant organisms and implement isolation precautions appropriately 1

Documentation and Incident Reporting

Implement structured patient safety incident reporting systems as recommended by WHO guidelines, ensuring all near-misses and adverse events are documented. 1 Near-misses are incidents that could have caused harm but were intercepted; documenting these allows system-level improvements. 1

Adverse events occur in 23.6% of all admissions, with 22.7% being preventable. 4 Your documentation must reflect systematic assessment and prevention efforts across all eight harm factors. 1

Common Pitfalls That Lead to Litigation

• Discharging patients based solely on medical stability without psychiatric clearance when mental health concerns exist 5
• Failing to ensure 24-48 hours of clinical stability before discharge 1, 3
• Not scheduling follow-up appointments before discharge or failing to ensure patients have reliable access to care 1, 3, 5
• Inadequate medication reconciliation and lack of pharmacist counseling 1
• Missing VTE prophylaxis in at-risk patients 2
• Inadequate informed consent processes without patient recall verification 2
• Premature removal of central lines without considering infection prevention benefits of antibiotic-impregnated catheters 2

Culture of Safety

Preventable harm affects 6.8% of all admissions, with 1.0% experiencing serious or higher severity preventable events. 4 Create an environment where staff can rapidly identify patients most vulnerable to multiple preventable harms and implement integrated prevention strategies rather than fragmented, single-risk approaches. 1

The complexity and volume of safety guidance necessitates integrated, accessible protocols that support real-time decision-making rather than overwhelming clinicians with separate checklists for each risk factor. 1