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Preventing Medical Errors: Best Practices for Mental Health Professionals -Revised 2014
Introduction
Susan is a 63 year-old woman who had been in therapy with Dr. Klein for 6 months, dealing with issues of grief and loss due to the recent death of her husband. The relationship between Susan and her husband had been quite conflictual, and Susan described a pattern of somatic illnesses that allowed her to elicit care and concern from a generally unresponsive man.
Prior to a scheduled appointment, Dr. Klein receives a call from Susan stating that she is experiencing chest tightness, shortness of breath and dizziness. Dr. Klein calms Susan down, stating that these symptoms are only anxiety, and encouraged her to keep her appointment.
When Susan does not arrive for her appointment, Dr. Klein is slightly concerned, but he thinks that maybe the anxiety was too great to allow her to drive. He later gets a call from Susan’s son, indicating that he had taken her to the hospital and that she had suffered a mild heart attack.
The saying “to err is human” is one that most people are familiar with, but some errors, such as the one described above, can have potentially tragic consequences. A landmark 2000 report, To Err is Human: Building a Safer Health System by the Institute of Medicine, brought attention to the issue of preventable medical errors. This report focused primarily on medical settings. According to this report, a between 44,000 and 98,000 Americans die each year as a result of medical errors. A subsequent report published in 2012, however, found that approximately 200,000 Americans die from preventable medical errors including facility-acquired conditions, and that millions may experience errors (Andel et al. 2012). Additionally this study looks at the economics of medical errors, and estimates that such preventable errors cost between $735 billion to $980 billion annually. Anders (2012) concludes that quality care is not being delivered consistently throughout U.S. hospitals, and that poor quality is costing payers and society a great deal.
The mandate for increased quality is important. “To err is human” provides several means for reducing medical errors, such as: 1) Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety; 2) Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems; 3) Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care, and 4) Implementing safety systems in health care organizations to en-sure safe practices at the delivery level.
Five years after this landmark report, Leape & Berwick (2005) published a follow-up examining whether the report has had an impact on reducing medical errors. They found that although the changes are not as sweeping as desired, attitudinal changes in organizations have occurred. There has also been focus on medical errors at a federal level, with Congress funding patient safety research through the Agency for Healthcare Research and Quality (AHRQ) (see http://www.ahrq.gov/).
Another important result of “To err is human” has been changes in the practice of health care. In 2010, The Joint Commission and Accredited Health Care Organizations (JCAHO), the group that provides accreditation to U.S. hospitals and other health care facilities began requiring hospitals to implement 11 safety practices, including improving patient identification, communication, and "surgical site verification" (marking a body part to ensure surgery is performed on the correct part). These National Patient Safety Goals have been reviewed annually, and include mandates for behavioral health settings. The behavioral health goals and an example of each are listed below:
· Improving the accuracy of patient identification (such as by taking photographs of patients on admission to behavioral health settings)
· Improving the effectiveness of communication among caregivers (such as by eliminating confusing abbreviations in notes or orders)
· Improving the safety of using medications (care taken with medications that have similar names)
· Reducing the risk of health care-associated infections (such as through adequate handwashing procedures)
· Accurately and completely reconciling medications across the continuum of care (such as through providing discharge summaries with medications clearly indicated)
· Encouraging patients’ active involvement in their own care as a patient safety strategy
· Identifying safety risks inherent in its patient population (such as individuals at risk for suicide)
Although many of these goals are more applicable to hospital rather than outpatient settings, goals such as encouraging patients to be active in their own care, increasing communication among treatment professionals and identifying risk factors are universal, as is the spirit of the Joint Commission recommendations. One principle commonly found in the ethical codes of counselors, social workers and psychologists is that of “beneficence and nonmaleficence”. Simply put, these codes states that clinicians strive to “do no harm” to those with whom we work. The American Psychological Association (2002) Ethical Principles of Psychologists, for example, states that “in their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research.” It goes on to outline the areas that could potentially jeopardize psychologists’ ability to help those with whom they work.
This course will examine the impact of medical errors on patients in mental health settings. It will reference best practices and ethical guidelines that can help to reduce and prevent medical errors. The 2011 version of this document includes updated references that will allow you to seek additional clarification on important points when needed.
Objectives:
After finishing this course, the participant will be able to:
- Discuss the Joint Commission’s National Patient Safety Goals for behavioral health
- Define “Medical Errors”
- Recognize approaches to prevent medical errors
- Utilize Root Cause Analysis process to evaluate medical errors
- Identify medical errors common in medical health
- Review ethical guidelines related to competence (including multicultural competence), informed consent, confidentiality and mandated reporting
- Discuss the Health Insurance Portability and Accountability Act (HIPAA)
- Discuss trends in assessment of suicide
- Describe assessment of medical conditions that present as psychological problems
- Describe reasons that accurate differential diagnosis is needed
Definition of Medical Errors
How do we define medical errors? Medical errors are mistakes made by mental health professionals within the normal work of their practice and which result in harm to the patient” (http://medical-dictionary.com/). All errors constitute a failure in service delivery have consequences for people at a time in which they are vulnerable (National Academy of Sciences, nd). Medical errors range from relatively minor ones that do not have lasting results or can be easily rectified, such as misdiagnosing an adjustment disorder as a depressive disorder, to those with more serious consequences such as failing to act to attain help when a client threatens self-harm.
Corey, Corey & Callanan (2010) suggest that one framework for studying errors is to break them down by type. They identify two types of errors: acts of commission and acts of omission. Clinicians commit acts of commission when they make mistakes, such as incorrectly diagnosing someone. Clinicians commit acts of omission when they fail to act in some way, such as a failure to report child abuse. Although it is not necessary to specifically identify medical errors using this schema, it provides a useful set of questions for the mental health professional: Am I doing everything I can within best practice guidelines? Have I missed doing something I could do?
In addition to the National Patient Safety Goals, JCAHO defines the most acute medical errors, which they term “sentinel events.” JCAHO’s Sentinel Events Policy was revised in 2013 (Full text of this article is available at http://www.jointcommission.org/assets/1/6/CAMBHC_2012_Update2_21_SE.pdf. Sentinel events are “unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof”. The phrase, "or the risk thereof" suggests that should such an event recur, it would carry a significant chance of an adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. The terms “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events. JCAHO’s policy has four goals: 1). To have a positive impact in improving care, treatment, or services to individuals served and preventing sentinel events; 2). To focus the attention of an organization that has experienced a sentinel event on understanding the factors that contributed to the event (such as underlying causes, latent conditions and active failures in defense systems, or organizational culture), and on changing the organization’s culture, systems, and processes to reduce the probability of such an event in the future; 3). To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention, and 4). To maintain the confidence of the public and accredited organizations in the accreditation process.
It is important to note that JCAHO makes a distinction between an adverse outcome that is primarily related to the natural course of the individual’s illness or underlying condition and a death or major permanent loss of function that is associated with the treatment or lack of that condition, or otherwise not clearly and primarily related to the natural course of the individual illness or underlying condition.
Examples of sentinel events include: An individual served commits suicide within 72 hours of being discharged from a behavioral health care setting that provides around-the-clock care; Prescribed medication results in a loss of function or death; Any elopement, or unauthorized departure, of an individual served from an around-the-clock care setting resulting in a temporally related death (suicide, accidental death, or homicide) or major permanent loss of function.
While these examples refer to inpatient settings a more realistic idea of medical errors that impact mental health professionals can be gleaned from malpractice data. Most malpractice suits are similar to medical errors in other fields as they involve a situation in which the treatment provider deviates in some way from accepted standards of practice and this deviation results in harm to the client. The majority of malpractice cases do not stem from unforeseeable problems, but rather from situations that could have been avoided if only they were recognized and anticipated. The following is a list of malpractice claims against psychologists over a 15-year period (Pope, 2003). The list is presented in descending order of frequency.
· Sexual violations
· Incompetence in developing or implementing a treatment plan
· Loss from evaluation
· Breach of confidentiality or privacy
· Improper diagnosis
· Other (a category of individual claims not falling into any other category)
· Suicide
· Defamation (e.g., slander or libel)
· Countersuit for fee collection
· Violation of civil rights
· Loss of child custody or visitation
· Failure to supervise properly
· Improper death of patient or third party
· Violation of legal regulations
· Licensing or peer review issues
· Breach of contract
Like the medical errors cited in the JCAHO listing, these situations which have been the focus of legal proceedings, occur within vulnerable populations and have the propensity of causing harm to the client. As a review of this list shows, these offenses can occur across many practice settings.
Root Cause Analysis
One approach to addressing medical errors is Root Cause Analysis - a retrospective approach to analyzing errors that has its basis in industrial psychology. As the name suggests, root cause analysis attempts to identify the underlying cause of a problem so it can be addressed, rather than simply treating the presenting symptoms. Root Cause Analysis assumes that mistakes do not just happen but that they can be traced to identifiable causes. This allows the person or organization that made the mistake to take steps to ensure that it does not occur again. The product of the root cause analysis is an action plan that identifies the strategies that the organization intends to implement in order to reduce the risk of similar events occurring in the future.
The National Center for Patient Safety (http://www.va.gov/NCPS/rca.html) states that the goal of a Root Cause Analysis is to determine
1) What happened
2) Why did it happen
3) What to do to prevent it from happening again.
When you use Root Cause Analysis you will generally find three types of causes (http://www.mindtools.com/pages/article/newTMC_80.htm):
· Physical causes – Tangible causes such as material items failing in some way. An example of this would be if a psychiatric medication caused an adverse reaction
· Human causes - People did something wrong or did not do something that was needed. An example of this would be a therapist failing to take precautions to ensure the safety of a suicidal patient
· Organizational causes - A system, process, or policy that people use to make decisions or do their work is defective. An example of this would be an organization policy that delays the reporting of child or elder abuse
In the remainder of this course, we will be using this approach to Root Cause Analysis to analyze vignettes that involve mental health medical errors. This paper will cite the appropriate sections of the APA Ethics Code (2002) when discussing these vignettes.
Competence
Mental health professionals can avoid many medical errors. There is a direct relationship between minimizing medical errors and maintaining professional competence. The issue of competence is important, and the APA established a task force to look at issues in professional competence (see http://www.apa.org/ed/resources/competence-report.aspx) for the final version of the 2006 report. The APA has subsequently come out with Revised Competency Benchmarks for Professional Psychology (2011), as well as A Guidebook for Competency Benchmarks (2012). Please see http://www.apa.org/ed/graduate/benchmarks-guide.aspx.