medical errors

Medical Errors

As Required Per Florida Statute 456.13(7)

Florida Statute 456.013(7)

The board … shall require the completion of a 2-hour course relating to prevention of medical errors as part of the licensure and renewal process.

The 2-hour course shall count towards the total number of continuing education hours required for the profession.

The course shall be approved by the board or department, as appropriate, and shall include a study of root-cause analysis, error reduction and prevention, and patient safety.

Purpose

The purpose of this course is to view the prevention of medical errors and includes the perspective of mental health professionals, psychologists and dieticians.

Objectives

At the conclusion of this course, the participants will be able to: – Identify major causes of medical errors

conducted by health professionals.

–Describe the effects of medical and mental errors on patient safety and care.

– Identify approaches to prevent and correct errors.

–Describe methods to keep both clients and providers safe.

Erring on the Side of Human

Factors for Patient Safety (APA, 2007, Institute of Medicine Report)

On December 7, 1999, the Institute of Medicine (IOM) dropped a bomb during what would have been a quiet congressional recess.

The "bomb" was a report entitled "To Err is Human: Building a Safer Health System," identifying medical error as the third leading cause of death in the United States.

Medical Errors

Medicine has traditionally treated errors as failings on the part of individual providers, reflecting inadequate knowledge or skill. The systems approach, by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems. (AHRQ, 2012)

Complexity of Medical Error and Injury Issues (APA, 2007)

Medical error is usually the result of a confluence of circumstances rather than simply one person making a mistake, so reducing medical error and injury cannot be accomplished simply by identifying and punishing individuals who have made errors.

Instead, most experts believe that reduction depends on addressing error systemically.

That is, it depends on understanding the relationship between proximal and distal causes of error and altering the causal stream, so that errors are not facilitated.

Reduction of error and injury also depend on understanding success, since medical-setting studies show that far more accidents are waiting to happen than actually happen.

Clearly, error in medicine (as in any complex system) involves understanding how people perform, how people think, how people communicate with one another, and how people interact with technology in complex organizational systems.

So a systems approach to understanding both safety and error involves multiple domains within scientific psychology.

Medical Errors

This systems approach to reducing error makes sense to all of us in the fields of social work, mental health and psychology.

Medical Errors

It fits well with how we typically conceptualize problems.

Medical Errors

Medical errors can be broken down into 2 types

Acts of commission

Acts of omission

Medical Errors

Acts of commission

–These are things that you DO which are mistakes

–Examples of acts of commission would include:

Incorrect diagnosis

Sexual misconduct

Medical Errors

Acts of omission

–These are things that you FAIL TO DO that are expected

–Examples of acts of omission would include:

Failure to keep adequate records

Failure to report child abuse

Medical Errors

Both acts of commission and omission are judged against prevailing standards of practice for your profession

Medical Errors

Simple steps

–Become a member of your professional organization

–Read board findings / minutes

–Keep your professional skills current

–Use supervision regularly

–These steps can make you aware of the mistakes of others in your field and help you avoid them

Potential Errors within a

Psychological Setting

Florida Board of Psychology finds each of these errors so serious, they are specifically mandated as content within this course . . .

Potential Errors within a

Psychological Setting

Inadequate assessment of suicide risk

Failure to comply with mandatory abuse reporting laws

Failure to detect medical conditions presenting as a psychological disorder

Inadequate Assessment

Of Suicide Risk

This may be the worst case scenario for medical errors

–Risk of death is high

–Professional responsibility to assess risk exists

–Use Florida Baker Act for imminent risk

–When in doubt - Consult !

Failure To Comply With Mandatory

Abuse Reporting Laws

Psychologists, social workers and other mental health professionals are trained to identify child and elder abuse

Although other professionals are required to report suspected abuse, clearly those in mental health understand the importance

When in doubt, report suspicions

Failure To Detect Medical Conditions

Presenting As A Psychological Disorder

Many psychological disorders present with physical symptoms that are associated with medical conditions

First rule out all medical conditions by referring to the appropriate medical specialty

For example

–if a client presents with heart palpitations and shallow breathing, treatment for panic attacks is only appropriate after it is determined that they do not have a heart condition

For example

–if a client presents with trouble sleeping, loss of interest and weight loss a diagnosis of depression is only appropriate if they do not have a medical illness causing these symptoms

Worst Case Scenarios

Death of a Client - Could be due to either acts of commission or omission

Medical errors that result in –Suicide

–Homicide

Suicidal Clients

Medical errors with suicidal clients

–Failure to properly diagnose

–Failure to properly treat

–Failure to Baker Act when appropriate

– Improper use of contracts

Homicidal / Violent Clients

Medical errors with homicidal or violent clients

–Failure to diagnose accurately

–Failure to properly treat

–Failure to Baker Act appropriately

–Failure to exercise Duty to Warn

– Improper use of contracts

–Failure to separate violent clients

Homicidal / Violent Clients

Duty to Warn

Duty to Protect -

– In Florida this usually means Baker Act

Tarasoff applies

Practice Guidelines

Exercise proper professional care

This includes:

–Referring out when you do not have the expertise to treat effectively

–Seeking supervision and consultation

–Updating your own clinical skills to keep up with scientific advances in the field

Practice Guidelines

Consult when necessary

It is good practice to consult with an experienced clinician regularly and often

–Discuss difficult cases

–Seek advice / expertise

–No one can be an expert at everything

Practice Guidelines

Take careful histories and advise clients:

–Fully informed consent

–Limits of confidentiality

–Have signed forms on file

–Rights and responsibilities

Practice Guidelines

Document all interventions

– Inadequate records can easily result in medical errors

–Failure to maintain sufficient client records can lead to difficulty with the board

–Client record requirements will be reviewed in detail later in this presentation

Practice Guidelines

Create and follow a clear protocol regarding duty to warn and contingency plans

–Develop protocols for all high risk situations that you are able to predict in advance

–These protocols will vary from agency to agency and population to population

Practice Guidelines

Develop risk management procedures

– If you have difficulty generating procedures, read – practice guidelines for most situations are easy to find from your professional organization

– It is easier and safer to develop these procedures when there is no crisis to be resolved immediately

Expressed & Informed Consent

Expressed and Informed Consent is: - Consent voluntarily given in writing,

by a competent person, after sufficient explanation and disclosure of the subject matter involved to enable the person to make a knowing and willful decision without any element of force, fraud, deceit, duress, or other form of constraint or coercion.

Expressed & Informed Consent

What does incompetent to consent to treatment mean?

- A person’s judgment is so affected by his or her mental illness that the person lacks the capacity to make a well-reasoned, willful, and knowing decision concerning his or her medical or mental health treatment

Psychotherapist – Client

Relationship

This relationship is established once services, psychotherapy, counseling, assessment or treatment are rendered

Relationship

A contract, scheduling of appointments, or payment of a fee are not necessary conditions to establish that a relationship exists

Relationship

This relationship once established is deemed to continue for a minimum of 2 years after the termination of psychotherapy or the last date of professional contact with the client

Client Records Requirements

Psychological Report, Psychosocial or Assessment

Treatment Plans

Progress Notes

Discharge Summaries

Basic client information

Treatment or evaluation session dates, including cancellations and phone contacts

Diagnosis, if applicable

Interventions and results

Client’s consent documents, releases, and consultations

Financial transactions

For social workers, mental health counselors and marriage and family therapists

Records must be kept for 7 years after termination

Psychologists must keep all records for 3 years – after 3 years, they may keep a summary of the record.

The summary must be kept for 7 years after termination

Confidentiality, Record Keeping,

Mandatory Reporting

Confidentiality Waivers refer to Ch. 394.4615

Confidentiality has its limits

Clients must be fully informed to make informed choices

Documentation must be thorough

Limits to Confidentiality

Duty to warn

Mandatory reporting – Child / Elder abuse and neglect

Multidisciplinary teams

Supervision

Limits to Confidentiality

HIV patients

Minors’ records

Group counseling

Health plans’ information gathering

Mandatory Reporting

Children, Elderly, Disabled Adults

–Abuse

–Neglect

–Abandonment

For some disciplines (medical)

–Threats to public health (STDs)

Mandatory Reporting –

Chapter 39.201

Chapter 39.201 requires mandatory reporting of child abuse, abandonment, or neglect; mandatory reports of death; central abuse hotline

415.101 Adult Protective

Services Act

415.1034 Mandatory reporting of abuse, neglect, or exploitation of vulnerable adults; mandatory reports of death.

415.101 Adult Protective

Services Act

415.104 Protective investigations of cases of abuse, neglect, or exploitation of vulnerable adults; transmittal of records to state attorney.

Title XXIX Chapter 394 The

Florida Mental Health Act

“The Baker Act”

Mental Illness – Definition

[F.S. 394.455 (18)]

Impairment of the emotional processes that exercise conscious control of one’s actions or of the ability to perceive or understand reality, which impairment substantially interferes with a person’s ability to meet the ordinary demands of living, regardless of etiology.

Mental Illness – Definition

[F.S. 394.455 (18)]

For the purposes of this part, the term does not include retardation or developmental disability as defined in Chapter 393, intoxication, or conditions manifested only by antisocial behavior or substance abuse impairment.”

Disciplinary Guidelines, Board

Orders

Please refer to F.S. 490

Review of guidelines, probable cause,

title violations, violations of descriptive

terms of service, minor violations,

citations, sexual misconduct, terms of

probation, mediation offenses, and

supervision by disciplined practitioner.

Sexual Misconduct

Defined by Chapter 64

It is sexual misconduct for a psychotherapist to engage, attempt to engage, or offer to engage a client in sexual behavior, or any behavior, whether verbal or physical which is intended to be sexually arousing including kissing, sexual intercourse, (etc).

Prevention And Analysis

Root-cause analysis

Error reduction & prevention

Patient Safety

Root Cause Analysis

Root cause analysis helps identify what, how and why something happened, thus preventing recurrence.

Root Cause Analysis

Root causes

–Are underlying

–Are reasonably identifiable

–Can be controlled by management

–Allow for generation of recommendations

Root Cause Analysis

The process involves data collection, cause charting, root cause identification

Recommendation generation

Implementation

Root Cause Analysis

Example

Understanding why an event occurred is the key to developing effective recommendations.

Root Cause Analysis

Example

Lets suppose that you have a practice that includes a lot of patients with the diagnosis of Major Depression

Root Cause Analysis

Example

Now lets suppose that you do your own billing and that it requires that you enter the DSM diagnostic code

Root Cause Analysis

Example

What if you enter the code incorrectly?

Root Cause Analysis

Example

And based on the DSM diagnostic code, the client’s claim for insurance is denied.

Root Cause Analysis

Example

Because insurance companies often deny claims for mental health.

You assume that they will not pay for treatment.

Root Cause Analysis

Example

You inform the client that their insurance claim was denied.

They report that they are sure that they have coverage for mental health services.

Root Cause Analysis

Example

Some possible recommendations might be . . .

Root Cause Analysis

Example

Private pay for treatment

Use a short term treatment plan

Refer to a mental health center for treatment

Root Cause Analysis

Example

But in reality, it was a medical error that is the problem.

And a root cause analysis can help to determine the source of the error.

Root Cause Analysis

Example

Root Cause Analysis theory states that generally, mistakes do not just happen but can be traced to some well-defined causes.

Root Cause Analysis Another Example

Identifying that poor insurance coverage is the problem does not help.

Mainly because nothing can be done about a client’s insurance coverage.

Root Cause Analysis

Root cause analysis investigates to determine why an error took place and what the organization can do to prevent recurrence.

Error Reduction and

Prevention

Identifying root causes is the key to preventing similar recurrences.

If you are able to determine that the source of the problem is that the diagnostic code was entered incorrectly – you solve the problem.

Error Reduction and

Prevention

An added benefit of an effective root cause analysis is that, over time, the root causes identified across the population of occurrences can be used to target major opportunities for prevention and improvement.

Error Reduction and

Prevention

In this example, you can establish a procedure for checking the DSM diagnostic code before submitting an insurance claim.

Error Reduction and

Prevention

When this procedure is applied to all of your clients, insurance claims are less likely to be denied when they should be paid.

Patient Safety

“First, Do no harm”

Act within your scope

Follow Code of Ethics

Seek supervision

Contract when appropriate

Checklists

“A checklist is an algorithmic listing of actions to be performed in a given clinical setting, the goal being to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering and have played a major role in some of the most significant successes achieved in the patient safety movement.” (AHRQ, 2012)

Checklists

Used by pilots in pre-flight to find defective equipment, identify potential problems and improve safety

Recent studies have found that checklists improve patient outcomes when done before surgery (AHRQ, 2012)

Checklists

“The field of cognitive psychology classifies most tasks as involving either schematic behavior, tasks performed reflexively or "on autopilot," or attentional behavior, which requires active planning and problem-solving.” (AHRQ, 2012)

Checklists

“Failures of schematic behavior are called slips and occur due to lapses in concentration, distractions, or fatigue, whereas failures of attentional behavior are termed mistakes and often are caused by lack of experience or insufficient training.” (AHRQ, 2012)

Checklists

“In health care, as in other industries, most errors are caused by slips rather than mistakes, and checklists represent a simple, elegant method to reduce the risk of slips.” (AHRQ, 2012)

Checklists

“By standardizing the list of steps to be followed, and formalizing the expectation that every step will be followed for every patient, checklists have the potential to greatly reduce errors due to slips.” (AHRQ, 2012)

Checklist Controversies

“Checklists are a remarkably useful tool in improving safety, but care must be taken not to overemphasize their importance: they cannot solve every patient safety problem, and even when checklists are appropriate, certain co-interventions may be necessary to maximize their impact.” (AHRQ, 2012)

Checklists Controversies

However, “only certain types of errors can be prevented by checklists: errors in clinical tasks that involve primarily attentional behavior (such as diagnostic errors) require solutions focused on training, supervision, and decision support rather than standardizing behavior.” (AHRQ, 2012)

Human Factors Engineering

“Human factors engineering is the discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments.” (AHRQ, 2012)

Teamwork Training

Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. The need for improved teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings.

Safety Culture

High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work. Such organizations establish a culture of safety by maintaining a commitment to safety at all levels, from frontline providers to managers and executives. (AHRQ, 2012)

Conclusion

Medical errors are preventable.

Medical errors should be conceptualized systemically.

Root cause analysis can be used to develop recommendations

Follow professional practice guidelines to reduce error

Conclusion

Professional practice guidelines require that you:

–Act within your scope and expertise

–Keep current with continuing education

–Follow your Code of Ethics

–Seek supervision/consultation when appropriate

References

Agency for Healthcare Research and Quality. (2012). Patient Safety Primers. Retrieved

from: http://psnet.ahrq.gov/primer.aspx?primerID=14 on 08/20/2012.

Agency for Healthcare Research and Quality. (2012). Patient Safety Primers: Checklists. Retrieved from: http://psnet.ahrq.gov/primerHome.aspx on 08/23/2012.

Agency for Healthcare Research and Quality. (January, 2007). Care of adults with mental health and substance abuse disorders in U.S. Community Hospitals. AHRQ Publication No. 07-0008.

Agency for Healthcare Research and Quality. (March, 2005). 30 safe practices for better health care. AHRQ Publication No. 05-P007

Corey, G; Corey, M.S. & Callanan, P. (2007). Issues and ethics in the helping professions. Belmont: Thomson: Brooks/Cole.

Gosbee, J. (2012). (2012). Human Factors Engineering Can Teach You How to be Surprised Again. Agency for Healthcare Research and Quality. Retrieved from: http://webmm.ahrq.gov/perspective.aspx?perspectiveID=32 on 08/20/2012.

References

National Academy of Sciences (n.d.) Free executive summary: To err is human: Building safer health system. Retrieved October 2005 from http://www.nap.edu/catelog/9728.html

Rivas-Vasquez, R. A., Blais, M.A., Rey, G.J. & Rivas-Vazquez, A.A. (2001). A brief reminder about documenting the psychological consultation. Professional Psychology: Research and Practice, 32(2), 194-199.

Rooney, J.H. & Vanden Hevel, L.N. (July, 2004). Root cause analysis for beginners. Quality Progress. pp. 45-53.

University of South Florida: Louis de la Parte Florida Mental Health Institute. (Oct, 2005). Policy Brief. Suicide risk in the Florida Medicaid population.

Tarasoff v. Board of Regents of the University of California, 17 Cal. 3d 425, 551 (1976).

Florida Statues and Rules

Florida Statutes (F.S.):

– 39 Proceedings Related to Children – 90.503 Psychotherapist-Patient Privledge – 394 The Florida Mental Health Act or Baker Act – 415 Adult Protective Services Act – 490 Psychological Services – 491 Clinical, Counseling and Psychotherapy Services

Florida Administrative Code (FAC) :

– 64B4 Board of Clinical Social Work, Mental Health Counseling and Marriage and Family Therapy

– 64B19 Board of Psychology

Current Florida Statues and Administrative Code can be found at

www.leg.state.fl.us/statutes/index.cfm?Mode=View Statutes&Submenu=1&Tab=statutes

Florida Statues and Rules

Current Florida Statues and Administrative Code can be found by clicking the link below:

Florida Statues

If you are having problems with the link - copy and paste this address into

a web browser: http://www.leg.state.fl.us/statutes/index.cfm?Mode=View

Statutes&Submenu=1&Tab=statutes

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