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Summary: It would seem absurd, that if a physician admits
and facility assigns a nurse to care for a known violent patient,
that it has no legal obligation to protect that nurse against
violence. In this case, a psychiatric patient sought admission
to facility. On admission, he threatened to attack a nurse.
When the patient would follow through on his threat, the nurse
was denied legal recourse against the psychiatrist who could
have taken precautions against the attack.
The patient had a known violent history which included self-
mutilation and sexual abuse. He additionally has a long history
of alcohol and drug abuse placing him in a "high risk" category.
"Violence is also one of the most important reasons for admission
to psychiatric hospitals and the psychiatric units of general hospitals.
Up to 40 percent of persons admitted to the psychiatric wards of
general hospitals are violent immediately before admission. One
study found a prior arrest rate of 26 percent among patients admitted
to New York State mental hospitals; 8 percent of them had committed
violent crimes. In another study 23 of 60 consecutive persons
admitted to a mental
hospital had at some time battered their wives
or husbands. Over a period of three months, 8 percent of patients at
two large state hospitals committed at least one assault."2
He went to the facility seeking treatment and asked to be admitted.
On admission he was placed into the care of an attending physician/
psychiatrist. On admission a threat was made "to break a nurses' neck"
by the patient to the psychiatrist. This was clearly documented and
consistent with the patient's past psychiatric history.
"The duty to protect third parties has complicated the professional
lives of many therapists. Predicting violence is notoriously difficult,
and the chance that a threat will be carried out is low. Therapists must
evaluate and then reduce the risk, especially but not only when releasing
a patient from a mental hospital. They must inquire about potential
dangerousness when obtaining information on new patients or patients
whose condition is becoming worse."2
The patient would later follow-through on his threat.
The nurse was badly beaten that same day.
"The greatest risk of violence among patients entering psychiatric hospitals is created by drug intoxication, especially intoxication by
stimulants or sedatives, including alcohol. Other potentially dangerous
patients are suffering from neurological symptoms, schizophrenia, and
mania. Patients are more likely to be violent if they show both
aggressiveness and a low level of anxiety at admission. Among
hospitalized mental patients, assaults are associated not only with
hostility and suspiciousness but also with thought disorder, hallucinations,
excitement, anxiety, unusual thought content, suicidal or other self-
destructive acts, and low blood levels of antipsychotic drugs."2
The nurse would file suit against both the patient and the psychiatrist.
In review of the admission records and on obtaining expert testimony,
it was charged that precautions could have been taken to protect the staff.
"Most patient assaults in hospitals are directed at attendants, nurses,
occupational therapists, and other patients, but psychiatrists are also
vulnerable. About 40 percent of psychiatrists are assaulted during their
Despite the fact that an expert witness testified that the admission
assessment by the psychiatrist was "incomplete" and that no warning
was given to the staff of the patient's violent nature, the nurse's
complaint was dismissed.
"Patients and staff in mental hospitals have a right to be free from
violent assault, but it must be balanced against the right of patients to
be free of unnecessary medication and seclusion. Some staff members
fear that whatever approach they take, they will be held legally liable,
but both harm and legal damages are likely to be lower if they err
on the side of preventing violence."2
The nurse appealed.
Questions to be answered:
Does the physician have a responsibility to the staff of a facility
caring for his patients to warn or take precautions to provide for
If the patient had a known history of violence, should orders have been written on admission to deal with the verbalized threats
made against the nurse.
The court would note that there is no legal duty owed by a physician/
psychiatrist to protect individuals from a patient's violent attacks.
According to state law, such a duty would only exist under special
conditions where a "relationship" existed. The court refused to
accept that this "relationship" existed between the clinician and the nurse.
The argument was made that this attack against the nurse was
"reasonably foreseeable" given the patient's psychiatric history.
The court noted that "warning of violent potential" might not have
been given to the staff by the psychiatrist. It noted also that
according to expert testimony for the plaintiff the initial assessment
may not have been sufficient to evaluate the patient's potential for violence.
The court ruled that the above did not change the fact that no
applicable "duty to protect" existed between the psychiatrist and
the nursing/facility staff. It did not accept the expert testimony as
conclusive that the attack could have been anticipated.
This sets a frightening precedent for nurses caring for potentially
violent patients. It is common for psychiatric and geriatric patients
to become disoriented and dangerous.
When faced with this situation on a unit that may be short-staffed
to start with, the nurse is left with few alternatives but to do the
"best" with what resources are available.
Knowing that the facility may very well not support or defend
a nurse's actions, it is ultimately the patient that will suffer.
If as in this case, the beaten nurse was left with no legal means of
retribution and little support, it is a wonder we step in at all.
President and Fellows of Harvard College. 1991. Violence and Violent Patients. The Harvard Mental Health Letter. Retrieved August 15, 1999 from the World Wide Web: http://www.mentalhealth.com/mag1/p5h-vio2.html
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