**6. Improving the quality and safety of care for prisoners**

Health providers and services have a legal and moral obligation to provide safe care to people who are incarcerated. The United Nations Mandela minimum rules for the treatment of prisoners includes specific medical and health care requirements. Under the category of vulnerable groups of people, the United Nations state that governments have the responsibility to *"Ensure that prisoners with physical, mental or other disabilities have full and effective access to prison life on an equitable basis, and are treated in line with their health conditions"* [81: 7]. The section on medical and health services underscores that clinicians'*"… relationship with prisoners is governed by the same ethical and professional standards as those applicable to patients in the community"* including: *"ensuring the same standards of health care that are available in the community and providing access to necessary health-care services to prisoners free of charge without discrimination; evaluating, promoting, protecting and improving the physical and mental health of prisoners, including prisoners with special healthcare needs; adhering to the principles of clinical independence, medical confidentiality, informed consent in the doctor-patient relationship and continuity of treatment and care (including for HIV, tuberculosis, other infectious diseases and drug dependence);* [and] *an absolute prohibition of health-care professionals to engage in torture or other forms of ill-treatment, and an obligation to document and report cases of which they may become aware"* [81: 8].

The literature on the quality and safety of care for incarcerated persons also provides insights into potential ways of improving this care. These fall into three broad categories of improved treatment, improved education and training for both

#### *Patient Safety and People Who Are Incarcerated DOI: http://dx.doi.org/10.5772/intechopen.108942*

health professionals and prisoners, and improved coordination of care. The literature specifically suggests the need to improve the: diagnosis, screening and triage for those entering correctional facilities [51, 52, 64]; medical assessment and care in police custody [54, 82, 83]; therapeutic relationships between inmates and correctional healthcare staff [73, 84]. It also identifies the need to reduce polypharmacy [57], provide alternative mental health treatment other than medication [56], introduce short-course treatment for latent TB infection [74, 77] and the provision of care consistent with TB treatment guidelines [62], and finally allowing the self-administration of treatment by inmates [72, 84].

Other improvement strategies are based on the education of health professionals and or incarcerated persons. These include the need to improve training for healthcare professionals working in correctional facilities [60], including training to improve knowledge and attitudes among custodial staff [e.g. 64, 68, 69, 71, 73] and, on the other hand, the provision of health literacy education programs for incarcerated persons, especially understanding of the importance of adherence to treatment [e.g. 63, 64, 66, 71, 73]. One organisational strategy which has been suggested by numerous studies is the need to improve the co-ordination and communication between correctional and community-based health services to improve health care and continuity of treatment [e.g. 62, 75, 76, 78–80].

Finally, the John Jay College of Criminal Justice in New York proposed a set of patient safety standards for prisons, entitled "Patient Safety Behind Bars". These address most of the requirement of the Mandela rules, and specifically address: access to and the availability of care (including access to prenatal and postpartum care); establishing a culture of safety within the incarcerating organisations (including active safety leadership and a shift to a systems approach to the safety of care); addressing the needs of health care personnel (including training, addressing staff fatigue and burnout, ensuring adequate staffing and competency); medication management (including the use of computerized medication systems); management of transitions and communication (including ensuring timely access to specialists, tests and consultations); addressing specific conditions (ranging from chronic diseases and the provision of access to care after acute mental health problem); and finally the involvement of patients in their care and treatment (including informed consent, informed refusal, the provision of interpreters, patient notification of results, patient tailored decisions and the choice of advanced directives) [85].
