Dialogue Volume 12 Issue 3 2016 | Page 35

practice partner Patient Safety We use this forum to regularly report on findings from patient safety organizations, expert review committees of the Office of the Chief Coroner, and inquests. Mania can’t be safely managed in a long-term care setting photo: istockphoto.com A review into the death of a man with a complex psychiatric history has prompted the Geriatric and Long-Term Care Review Committee (GLTCRC) to remind physicians that admission history and physicals for long-term care residents need to be done in a timely fashion. The GLTCRC is a committee of the Chief Coroner’s office. The Committee’s review found that the patient had not been examined by the long-term care physician until three weeks into his admission to the facility. During those three weeks, he was unstable in terms of his behaviours. There was no blood work obtained during the admission to long-term care. It is documented that the patient lost 5.4 kg during those first three weeks, yet the long-term care physician did not comment on the loss. In long-term care, the patient fluctuated between aggression and over sedation and only five days before his discharge to hospital was a referral sent to consult the local psychogeriatric outreach team. The Committee also stated that the case serves as a reminder to health-care providers that a diagnosis of dementia does not mean that individuals with a lifelong history of serious mental illness (i.e., bipolar disorder, schizophrenia, depression) are no longer at risk of exacerbations of their mental illness. “Mania is not an illness state which can be safely managed in a long-term care setting by primary care practitioners. Individuals with mania require urgent psychiatric assessment and further specialized care,” stated the Committee. Issue 3, 2016 Dialogue 35