Patient Safety, Quality Improvement, Professionalism, and Ethics
Patient safety, quality improvement, professionalism, and ethics
Safety begins with suicide risk assessment: ideation, intent, plan, means, prior attempts, substance use, agitation, psychosis, and protective factors. Document a safety plan and collateral information. Know involuntary commitment criteria (mental illness plus imminent danger to self or others, or grave disability) and the difference between capacity and competence. Capacity is clinical and decision-specific: understanding, appreciation, reasoning, and expression of choice. Competence is a legal determination. Informed consent requires capacity, disclosure, voluntariness, and understanding. Confidentiality has exceptions: danger to self or others, child or elder abuse, court orders, and some public-safety reporting. Tarasoff-style duty to protect may require warning or protective action. Professional boundaries, conflicts of interest, and error disclosure are testable. Quality improvement uses PDSA cycles, root cause analysis, and measurement; it is not blame. Morbidity and mortality conferences examine systems. Documentation should be timely, factual, and nonjudgmental. Traps: equating capacity with compliance; breaching confidentiality without a legal exception; calling a patient incompetent because they refuse treatment; missing that a patient with capacity can refuse care; ignoring a duty to protect; and treating QI as individual punishment. Worked example: a patient with schizophrenia refuses antibiotics for cellulitis but understands the risks and can reason. They have capacity; treat only if emergency criteria or imminent harm are met. Rule of thumb: capacity is decision-specific, and safety overrides confidentiality only when danger is serious and imminent.