CMPA Perspective March 2016

Inadequate staff or monitoring was particularly significant in
the CMPA restraint cases where the outcome was patient
death. These cases call attention to the need for adequate
resources and equipment to effectively monitor and safely
secure restrained patients.
The cases also indicate that physicians should follow current
standards of care and institutional policies when giving
medication, including appropriate monitoring and follow-up.
Medical-legal risk can also be mitigated by following
guidelines on the use of restraints; complying with laws,
rules, regulations, and accreditation standards; and having
appropriate staff training and protocols for observation and
treatment. 3,4,5 Best practices on restraints generally emphasize
that institutions should strive to be restraint free. Restraints
should be considered extraordinary measures and only used
when alternate interventions fail. When considered necessary,
they should be tracked and employed for the shortest time
possible, and the restraint order should be regularly revisited.
Some institutions mandate a debriefing shortly after a
patient has been restrained. In addition, Accreditation
Canada requires that institutions being surveyed provide
information about their restraint policies and practices.
By considering expert testimony in CMPA’s medical-legal
cases and current best practices, and by complying with
applicable laws, policies, and standards, the risks and
adverse effects from restraints should be minimized.
Risk management considerations
When using restraints physicians should consider the
following risk management measures, which are based on
the experts’ opinions in the analyzed CMPA cases:
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Attempt to de-escalate the situation using
other methods.
Obtain an adequate history, including medications
and co-morbidities.
Conduct an appropriate physical examination.
Explain the plan for the use of restraints calmly and
clearly to patients or substitute decision-makers.
Document the rationale for using restraints and use the
least restrictive means necessary.
Ensure clear and readily available policies and
procedures for monitoring restrained patients and
ensure appropriate training of staff.
Adhere to applicable regulations, laws, and
accreditation standards.
1. Rakhmatullina, M., Taub, A., Jacob, T., “Morbidity and mortality associated with the utilization of restraints: a review of literature,” Psychiatric Quarterly (2013) Vol. 84 No. 4, p.499-512.
2. Government of Québec, An Act Respecting Health Services and Social Services, S -4.2. Retrieved on March 4, 2015 from: http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/
telecharge.php?type=2&file=/S_4_2/S4_2_A.html.
3. Emanuel, L.L., Taylor, L., Hain, A., Combes, J.R., Hatlie, M.J., Karsh, B., Lau, D.T., Shalowitz, J., Shaw, T., Walton, M., eds., “PSEP - Canada Module 13d: Mental Health Care: Seclusion and
restraints, When all else fails,” The Patient Safety Education Program - Canada (PSEP - Canada) Curriculum. © PSEP-Canada Project, 2010. Accessed February 2, 2016 from: http://http://www.
patientsafetyinstitute.ca/en/education/PatientSafetyEducationProgram/PatientSafetyEducationCurriculum/MentalHealthModules/Pages/Mental-Health-Care-Seclusion-and-Restraint.aspx.
4. Registered Nurses’ Association of Ontario , “Promoting Safety: Alternative Approaches to the Use of Restraints,” 2012, Clinical Best Practice Guidelines. Accessed February 2, 2016 from:
http://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf.
5. American College of Emergency Physicians, “Use of patient restraints,” Clinical and Practice Management, April 2014. Accessed February 2, 2016 from: http://www.acep.org/Clinical---
Practice-Management/Use-of-Patient-Restraints.
8 cmpa perspective | march 2016