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Table 2 Example of preventability assessment instructions

From: Adverse events in psychiatry: a national cohort study in Sweden with a unique psychiatric trigger tool

T1 Coercion treatment–administrative failure

Definition

Failure in the documentation of decisions according to LPT or LRV or Time limits given for coercion were not followed or documented correctly.

To remember

The violation of rules may lead to the patient being custodial without legal support or not having his/her rights catered for, e.g., information and the possibility to appeal against coercion decisions.

Is the documentation of decisions adequate?

AE that can be found

The patient is exposed to authority handling without legal support, custodial and psychic suffering.

Preventability

If time limits were not followed in connection with coercion or if the documentation of coercion is incorrect, the AE is considered preventable.

  1. AE: Adverse event; LPT, LRV: Swedish laws of coercion in psychiatric and forensic healthcare