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Could checklists reduce harm?

Recently, I analyzed a series of 60 cases (2009-2012) from 22 states that I have been asked to review. Thirty-eight of these resulted in death and 14 resulted in serious disability. Only eight had no discernable serious harm. Here are some remarkable findings. In 49 of the 60 cases, the patient’s history or behavior was either ignored or disbelieved. Some of these cases demonstrated ineptitude and others demonstrated outright cynicism. Five patients were punished for their mental illness by custody staff, with either prolonged restraint or Taser.