Delivering the right care to the right patient at the right time in the right way is a historical challenge that has been appreciably exacerbated by modern medical complexities.
The serious problem of medical errors is not new. Even with the recent emphasis, there continues to be a significant amount of injury to patients caused by the delivery of medical care.
This course was developed to provide a foundation for a better understanding of what
medical errors are, where they most frequently occur, how to address
them using processes such as the root cause analysis and how to avoid them through error reduction and prevention techniques. Improvement approaches, analysis tools, reporting processes, and risk management issues for inpatient and residential programs will be discussed.
Patient and family participation will be highlighted as a key component of safety.
Finally, outpatient practitioner issues relating to medical errors will be explored. These
topics will explore ways to encourage safety and improve outcomes for patients.
As this course uses the term adverse event it is used to describe an injury caused by medical mismanagement rather than an underlying disease/condition of a patient or client.
The term error planning is used to describe the use of a wrong plan to achieve the desired aim and error execution is used to describe the failure of a planned action to be completed as intended. Not all, but a sizable number of adverse events are a result of medical errors. Careful analysis and then process implementation can help prevent these medical errors from happening.
As many professionals in the same industry work in very different setting, as you continue through this course, think about implications for your work environment and practice.
The Leading Causes of Errors
Health care professionals continue to be placed in situations wherein errors are bound to occur. For example, inexperience and poor training can lead to inaccurate diagnosing and treatment and a higher rate of human error. Inadequate staffing levels have been linked to an increase of adverse events. Overwork and fatigue have been shown to cause a significant decrease in alertness and concentration leading to errors. Reliance on memory, which is fallible, can also lead to compromised patient safety.
Most people believe that medical errors are the result of the failures of individual providers. When asked in a survey sixty-nine percent of respondents thought the problem could be solved through better training of health professionals. In actuality, the IOM emphasized that most of the medical errors are systems related and not attributable to individual negligence or misconduct. The best approach to reducing medical errors is to focus on improving the systems for caring for and treating clients and not to blame individuals.
Healthcare professionals are humans and, like everyone else, they do make mistakes.
Although research has shown that system improvements are key to reducing the error
rates and improving the quality of healthcare it is also important to explore why
professionals are prone to mistakes. Research in the healthcare industry, as well as in
other industries, such as long distance trucking, aviation and nuclear power have offered insight into how people make mistakes and how we can use this learning to improve systems and make patient care safer. Research supports that people make mistakes due to fatigue. Mistakes are more likely as people get tired. Inattention and distraction, when multiple events are occurring at the same time, can divert attention from the task at hand. Also, seeing what we expect to see because we are used to seeing it that way, even if it is incorrect often leads to mistakes that we don’t even recognize. Encountering a new situation in which we have not been trained and do not know how to handle can lead to using trial and error solutions often resulting in error. Communication problems and information transfer problems, this would include lack of communication, misinterpretation and using words that have more than one meaning, can contribute to errors. Legibility, such as handwritten notes and orders, which can lead to guessing can lead to errors. In the hospital setting, the labeling of medications or mislabeling equipment instructions may be misleading. Frequently, mistakes are made when the equipment, supplies or the environment are not conducive to the safest practices.
In the mental health field, professionals are bound to encounter many different types of clients. The patients are considerably varied with different conditions, preferences and openness. In many situations the client is the primary source of information from which a history is created, a diagnosis is made and a treatment plan is developed.
It is also relevant to expect any process involving multiple patients to be prone to have more failure.
Complex processes are more prone to failure because each additional step is a process is one more chance for a mistake to happen.
A process that involves human intervention, and counseling largely does, is more prone
to error. For example, automated functions often proceed smoothly and without
interruption, computer alerts, and calculators are examples of technology that maintain
process stability without needing people to do the work. Time constraints often go hand
in hand with errors. When time is limited for a process, or it must occur rapidly then
additional pressure and stress is applied to the people taking that action. Nerves often
get frazzled during rush hour traffic, so do they also get frazzled while trying to complete
a task, getting a report to the court system, moving a patient to an appropriate unit, or
trying to get medications to the patient in a timely manner. The last to note is heirarcherial
culture. When there is fear of reprisal it makes it difficult to raise issues for fear of being
embarrassed or being wrong.
Clearly, the reduction of errors 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.
Research shows that the majority of medical errors can be prevented. A landmark study
on medical errors indicated 70 percent of adverse events found in a review of 1,133
medical records were preventable; 6 percent were potentially preventable; and 24 percent
were not preventable. It is a common misconception that client safety can be improved by
simply reminding health care personnel to be more careful. To correct the root of medical
errors, instead of focusing on blaming an individual for an incident, the focus should be on
reviewing the processes and factors that surrounded the event. A change in focus can
occur only by health care professionals carefully evaluating their processes and previous
errors and then systematically making the positive changes. Improving patient safety is
about changing the culture in healthcare.
Hindsight is 20/20. Hindsight bias is the phenomenon where it seems obvious how an
error happened, but after the fact. However, before the error occurred it was not obvious
that the process or system was error prone. Hindsight bias is detrimental to accident
analysis and understanding because it narrows the focus of the cause of any failure without
considering the whole picture including all of the environmental and emotional issues,
which may surround the event. This approach will limit a complete and thorough
investigation and focus on individual action as the cause of the problem. We often jump
to conclusions without having all of the necessary information.
There are a number of methodological reasons why research in patient safety is particularly
challenging. Many practices, particularly in counseling, cannot be the subject of
double-blind studies because their use is evident to the participants. Also, capturing all
relevant outcomes, including “near misses and actually harmful events, are often very
difficult. Many effective treatment plans are multidimensional and sorting out precisely
which part of the intervention works is often quite challenging.
As researchers have concluded most medical errors cannot be prevented by perfecting
the technical work of individuals, instead implementing prevention techniques as a means
of crosschecking and monitoring progress is necessary to improve outcomes.
FMEA assumes that no matter how knowledgeable or careful people are, errors will occur
in some situations and may even be likely to occur. FMEA steps include first defining high
risk processes, identifying what could go wrong, the significance of the error and what
needs to be done to prevent failures.
How Miscommunication Can Translate Into Error
Listening skills are well noted as one of the most important counseling attributes, the way we talk and the words we use to describe an event help to shape treatment.
Whether communicating in group with clients, or talking with counselors in supervision redefining our culture for safety must include placing words in concepts and understanding the whys of why things happen. Think about the terms accident versus failure versus
error. Accident describes a breakdown in a system. Frequently, they are complex and they need analysis. Error suggests one cause, usually notes that of a human error. There is infrequently a single cause of any accident. An example, a client comes in to take
the SASSI (Substance Abuse Subtle Screening Inventory) which is a self-administered test for alcohol and other drug abuse, they fill out the answer form incorrectly, but this is not evident from just looking at the form. The clinician scores the test and develops a treatment plan with the score as a factor. If the client is not in the best therapeutic environment, is there one cause for this?
To prevent future errors we must learn from our mistakes. Let’s face it, we all make
mistakes. Mistakes happen in hospitals, they happen in outpatient settings, and they
happen in nursing homes. We, as professionals, need to feel safe enough and respect
our profession enough to acknowledge that they happen. The challenge is to avoid them,
and when mistakes do occur, to prevent them from causing harm to our clients. While
understanding the legal ramifications of such, we must admit that we made a mistake so
that others and we can learn from it.
Accidents are not isolated events; they are the result of a weakness in a system. Blame is
used to find an excuse for failure not to predict and prevent future incidents. A blameless
environment promotes comfort to report failures for study. What happened versus whose
fault is it; “what” uncovers facts, “who” always places blame.
I never understood why working in the mental health field, we did not support each other
better. We know how powerful words can be. Choose them carefully with the best end
result in mind.
Clients at Risk
Again, it is easy to think of the areas in the medical/surgical arena that medical errors
could occur. In actuality many disciplines are vulnerable to errors. They can occur in
nursing, dietary, physical therapy, occupational therapy, radiology, nuclear medicine,
laboratories, surgery, and many others including social services. Examples include a
clinician misreading the results of a test or drug screen or the dates in a court mandated
treatment file suggesting the client has completed 36 weeks of treatment when this isn’t
Many errors occur when clinicians and their patients have problems communicating.
This can certainly happen in the mental health field. A recent study supported by the
Agency for Healthcare Research and Quality (AHRQ) found that doctors (the same can
be said for many clinicians) often do not do enough to help their patients make informed
decisions. A key factor in effective psychiatric treatment is patient involvement.
Uninvolved and uniformed patients are less likely to accept the choice of treatment and
less likely to do what they need to do to make the treatment most productive. The goal
of safety programs is to create a non-punitive and blameless culture. This means that
when an error occurs instead of placing blame on the person involved, exploration of the
situation and the surrounding events should be analyzed. The reporting is necessary to
see what is wrong with the process or the procedure. A simple process mandating that a
colleague must proof all evaluations before being sent out or a supervisor must review test
results before a treatment plan is developed with the client can make a big difference in
accuracy. Administrators and leaders can make changes and improvements easier for
everyone to be a part of. The language of safety should be a positive one. Through
these changes staff is empowered. All staff aligning with the same agenda. Change
from individual blame to system identification to reduce the number of medical errors
and improve client outcomes.
Specific Areas of Concern for Errors in the
Mental Health Industry
Understanding that the nature of counseling is largely reliant on client information is a key
to recognizing where psychologists, counselors and social workers will be most vulnerable.
Great care should be taken when eliciting the client’s history. Several methods should be utilized to reduce missing important information. Paperwork the patient fills out that asks questions such as previous treatment and diagnosis can begin the process. Face to face
evaluation and assessment time can cross reference an understanding of the questions and further develop the picture of the person in front of you. Training in effective ways of building rapport and asking difficult questions can be helpful. The use of other
informants, with a release of information can be helpful. For example a spouse, sponsor or previous counselor can give additional information. Another area of frequent confusion in the inpatient setting is advanced directives and patient rights. Misinformation on these issues can lead to great frustration on the part of the patient and derail an otherwise productive therapeutic relationship. This is true for involuntary commitment, as well. A thorough understanding of your state requirements and a polished approach to explaining the rights and the process to the patient and family can make a dramatic difference. One of the biggest issues relating to error is confidentiality. It is crucial to the therapeutic
relationship, as well as for legal reasons, to be very clear on your professional, ethical and states legal requirement for confidentiality. Not only in expressing in advance to a client what is and what is not confidential, but also in the appropriateness and correctness of information being reported from a treatment perspective. Is it therapeutic for a client to have access to the notes you are making in their chart? Are the notes saying what you mean for them to say if for example a judge requests the chart? Do you have a correct history, the same history the probation officer or managed care case manager knows of, if not will the rest of your assessment look flawed?
Suicides by Mental Health Patients
Should suicide be considered the result of a medical errors? In some cases, it is.
For a number of years it has been recognized that a major means of suicide in
acute psychiatric units has been hanging from curtain or shower rails. The report
of the National Confidential Inquiry into Suicide and Homicide by People with Mental
Illness concluded that hanging from non-collapsible structures such as bed, shower
and curtain rails, is still the most common method among mental health in-patients.
This is despite the fact that collapsible rails are now readily available. These are
What Changes Should Be Considered To Keep Clients Safer?
Health care professionals continued to be placed in situations wherein errors are bound to
occur. For example, inexperience and poor training can lead to inaccurate diagnosing and
treatment and a higher rate of human error. Inadequate staffing levels have been linked to
an increase of adverse events. Overwork and fatigue have been shown to cause a significant
decrease in alertness and concentration leading to. Reliance on memory, which is fallible, can
also lead to compromised patient safety.
The core recommendations to reduce errors include:
1. Simplification, reduce the number of steps and handoffs.
2. Standardization, limit the variety of test instruments used, equipment, supplies, policies
3. Reduce reliance on your memory. Make client notes immediately after sessions.
4. Use checklist as reminders to ensure complete accurate actions. An example is to make
a checklist that goes in the front of a client file to make sure all of the necessary
paperwork such as the signed confidentiality statement, releases and notes are all in
5. Eliminate look-alikes and soundalikes, particularly for psychiatric nurses and pharmacists.
6. Eliminate similar labels that can reduce the chance of choosing the wrong item.
7. Training staff on patient safety error analysis techniques and tools and process
8. Increase communication feedback. Use feedback to modify or decrease error prone
9. Create a learning environment.
10. Teamwork. Use teams to promote both multidisciplinary perspectives in identification
11. Make appropriate environmental adjustments.
12. Identify factors in the environment that may contribute to errors and modify them
or correct them.
13. Adjust work schedules as needed. Identify factors in schedules that might contribute
to errors, modify and correct them.
The staff with the direct contact with the clients is the last line of defense between effective
care and a potential error. If we wish to accomplish our goal of protecting the patient from
medical errors then we must be proactive in examining risk prone areas in which we work.
Many times we get lucky and have what can be termed a near miss. A near miss error can be described as an error that got caught before it reached the patient. Identifying and analyzing errors that are considered “near miss” errors can give us the opportunity to prevent future harm by determining where the weak parts are in the care delivery system and then strengthening those areas.
An important aspect of effective care is to look at the age appropriateness of the treatment
and plans. The following factors must be considered 1) the clients emotional ability to
cooperate with care. 2) clients who need additional watching because they are a risk to
themselves or others or due to their inability to care for themselves. 3) for the psychiatric
nurse, reducing medication dosages per the doctor for children, elderly, and those with
conditions of impaired renal, liver and immune function. 4) ability of different age groups
to follow directions related to safety and asking for help. 5) assessing cultural differences
may also play and important part in safe and effective care. Always assess for any language
barriers that inhibit understanding about care and or safety. Explore cultural differences
in expressing psychiatric, emotional and healthcare concerns.
Most counselors are not licensed or trained to dispense medications, however in the case
of a psychiatric nurse who is also educated as a counselor, medication administration is an
extremely complicated task that many medical errors can be attributed to. The IOM study
estimates that as many as 7,000 patients die each year as a result of medication errors with
an estimated additional hospital cost of 4,700 dollars for each preventable medication error.
Medication errors can be broadly categorized into 4 major categories. The first, ordering
and prescribing accounts for 39%. The second, dispensing is approximately 12%. The
third, administration is 38% and transcribing is 11%. So, almost 80% can be described as
order, prescribing or administration. As this course is predominately developed for
counselors, social workers, therapists and psychologists, we will not go further into these
types of medication errors. For a more in-depth study of medication errors please refer to
the Medical Errors course in the nurse category.
Another area of concern is procedural mishaps. These may include a variety of errors that
occur or have the potential to occur while the client is navigating through the health care
system. These mishaps may be as simple as discharging a client from a residential program
without the proper discharge recommendations.
Patients are at risk for serious injury and organizations must deal with the financial liability
that results from such accidents. Those who are at most risk for fall are the elderly or
those under the influence of alcohol, other drugs or heavy medications. Falls may be
caused by environmental factors, such as clutter in the room, wet floors, rugs; psychological
factors; muscle problems or broken bones; non compliance; incomplete histories or lack of
identification of falls risk.
As noted by LifePoint Hospice, falls prevention basics include:
1) assessment of a patients risk of falling
2) assessment of environmental dangers
3) patient and family teaching
4) continuance monitoring
5)implementation of a patients specific plan for safety
providing a safe environment including removing any hazards, providing adequate lighting, lock beds and wheelchairs, placing objects within the reach of patients and always ensuring that there is a method for patients to call for assistance.
Patients Rights and Protections
Communication from the initial consent to treat to the disclosure of an unanticipated
outcome is paramount to effective, therapeutic safe care. Communication is the key.
All providers involved in the course of treatment should maintain open communication
with the client and as appropriate the client’s family.
Proper incident reporting identifies problem areas, provides the necessary information
to establish safe practices, systems to ensure proper treatment and accurate files and
to improve staff development. There are several barriers to reporting mishaps. Lack of
time, fear of punishment, losing referrals, being taken off of a managed care panel, fear
of being wrong, unclear reporting structures, or forgetfulness. An established line of
communication through your supervisor will assist in performance improvement processes.
The goal of any reporting system is to analyze the information gathered and to identify
ways to prevent future errors from occurring.
Clients develop through a variety of ways, seeing, hearing, touching and doing.
Remember to incorporate as many techniques as possible to ensure the maximum amount
learned and retained. Frequently, providing brochures and other written materials can help
to emphasis how the client and their family can better understand and help their treatment
along. Encourage patients to ask questions about their treatment plan and goals to be sure
Organizations successful in improving patient safety have designed systems to protect
against human shortcomings. They have made major strides in improving safety through
the use of system approaches such as automation, simplification, and standardization of
functions and equipment; practice guidelines or protocols; and teamwork that includes
checks and balances.
Furthermore, error reduction is a philosophy embraced throughout the organization from
top to bottom.
To improve safety in the modern health care system, similar philosophies must be
embraced and similar changes must be made. It is the knowledge that both opportunity
and potential for improvement exist in the health care system that leads to a call for
rigorous research focused on preventable system errors and improved patient safety.
Thank you for taking this course through BaysideCEU.com.
We appreciate you as a client!