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Medical Errors Prevention in Mental Health Back to Course Index



Susan told Renee that she would do the assessment paperwork on the new client in the lobby.  He was an 86 year old man presenting with alcohol and drug abuse.  He didn’t have anyone with him.  Renee got concerned when Susan hadn’t returned to the intake office.  She went to pop her head in and knew the problem right away.  

“Mr. Johnson, I need to know when the last time you had any alcohol or drugs.”

“Yes, I have a problem with alcohol.  I don’t do drugs.  I told you that.”

“I’m sorry.  I didn’t hear that.  When is the last time you drank any alcohol?”

“What?  I told you I drink alcohol.  Why are you asking me?  I already told you I drink.  You aren’t listening.”

“Mr. Johnson, I want to help you but I need to better understand the issue.  Did you drink today?”

“I can’t remember what I had for breakfast.  How would I remember the last time I used drugs?”

“Oh, I thought you hadn’t ever used drugs.  Is that what you are referring to?”

“I don’t understand why you keep asking about drugs.  I told you I drink.”

Susan completed the assessment reporting that Mr. Johnson drinks to excess regularly.  She had gone round and round with him and couldn’t get anyplace.  He was getting frustrated.  She was getting frustrated.  They would sort it out on the unit.

Mr. Johnson was not doing well on the unit.  He was physically sick, sweating, had abdominal cramps, diarrhea and muscle aches.  He was two days into alcohol abuse treatment before the unit learned about his dependence on heroin.  


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.


It has been 20 years since the Institute of Medicine brought attention to the issue of preventable medical errors through their To Err is Human:  Building a Safer Health System. The report defines the term medical error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”

Examples include adverse drug events, surgical injuries, suicides, restraint-related injuries or death, falls, and mistaken patient identities. Mandates for improvements to care quality are important.

1) They help with establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about patient safety;

2) They help with 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) Mandates raise performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care;

4) They assist with implementing safety systems in health care organizations to ensure safe practices at the delivery level; and,

5) They provide for a centralizing of our healthcare delivery system.

An important result of To Err is Human has been changes in the practice of health care.  However, Dr. Mark Chassin, MD, FACP, MPP, MPH, president and CEO of The Joint Commission reports, “We haven’t moved the quality and safety needle as much as we had hoped.  The health care industry has directed a substantial amount of time, effort, and resources at solving the problems, and we have seen some progress.  That progress has typically occurred one project at a time, with hard-working quality professionals applying a “one-size-fits-all” best practice to address each problem.  The resulting improvements have been pretty modest, difficult to sustain, and even more difficult to spread. ”  

Dr. Mark Chassin went on to say, “Over the next 20 years, I do believe we can achieve far higher levels of safety and quality, but only if we shift the improvement paradigm in three important ways: 

  1. Commit to zero harm. Conservative estimates report that invasive procedures on the wrong patient or body part occur about 45 times every week in the United States. The ultimate goal for any health care endeavor HAS to be zero harm, meaning: 
    • Zero complications for patient
    • Zero injuries to caregivers 
    • Zero episodes of overuse 
    • Zero missed opportunities to provide effective care 

That’s not an easy lift, and it may take longer than 20 years. Other industries have done it. US commercial aviation and nuclear power industries are now recognized worldwide for their exemplary safety records, because they’ve accepted nothing less than zero harm.  That achievement would not have been possible without the full commitment of industry leaders to the goal.  The same should be true for health care. We can no longer debate how much harm is acceptable. No amount of harm is acceptable. 

  1. Overhaul organizational culture. It falls on health care leaders to reverse the trend of staff being subjected to disrespectful and demeaning behavior when they raise concerns about safety and quality. Such behaviors, which are all too common, drive critical information about unsafe conditions underground, not to be discovered until patient harm results. 

The second part of the equation calls for leadership to institute programs that hold every caregiver—regardless of seniority or professional affiliation—accountable for consistent adherence to safety protocols and agreed-upon safe practices. Getting this equation right will go a long way toward removing the health care organization’s vulnerability to a myriad of risks. 

  1. Adopt the most highly effective process improvement methods. Health care safety processes very often fail at rates of 50% or higher. The improvements we have achieved over the past 20 years have largely resulted from health care organizations undertaking a series of focused projects, each one aiming to reduce a specific type of harm


The Joint Commission requires hospitals to comply with patient safety recommendations. These include goals for behavioral health.

The Behavioral Health Care and Human Services National Patient Safety Goals for 2021 are:

Improve the accuracy of the identification of individuals served.
Use at least two identifiers when providing care, treatment, or services.

Treatments covered by this goal include high-risk interventions and certain high-risk medications (for example, methadone). In some settings, use of visual recognition as an identifier is acceptable. Such settings include those that regularly serve an individual (for example, therapy) or serve only a few individuals (for example, a group home). These are settings in which the individual stays for an extended period of time, staff and populations served are stable, and individuals receiving care are well-known to staff.

–Rationale for NPSG.01.01.01–
Errors involved in misidentification of the individual served can occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-fold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier.

1. Use at least two identifiers of the individual served when administering medications or collecting specimens for clinical testing. The room number or physical location of the individual served is not used as an identifier. 

2. Label containers used for specimens in the presence of the individual served.

Improve the safety of using medications.
Maintain and communicate accurate medication information for the individual served.

Introduction to Reconciling Medication Information
The large number of people receiving care, treatment, or services who take multiple medications and the complexity of managing those medications make medication reconciliation an important safety issue. In medication reconciliation, a clinician compares the medications the individual served should be using (and is actually using) to the new medications that are ordered for the individual and resolves any discrepancies.

The Joint Commission recognizes that organizations face challenges with medication reconciliation. The best medication reconciliation requires a complete understanding of what the individual served was prescribed and what medications he or she is actually taking. It can be difficult to obtain a complete list from every individual in an encounter, and accuracy is dependent on the ability and willingness of the individual served to provide this information. A good faith effort to collect this information is recognized as meeting the intent of the requirement. As more sophisticated systems evolve (such as centralized databases for prescribing and collecting medication information), the effectiveness of these processes will grow.

This National Patient Safety Goal (NPSG) focuses on the risk points of medication reconciliation. The elements of performance in this NPSG are designed to help organizations reduce negative outcomes associated with medication discrepancies. Some aspects of the care, treatment, or services that involve the management of medications are addressed in the standards rather than in this goal. These include coordinating information during transitions in care both within and outside of the organization (CTS.04.01.01), education of the individual on safe medication use (CTS.04.01.03), and communications with other providers (CTS.06.02.05).

In settings where medications are not routinely prescribed or administered, this NPSG provides organizations with the flexibility to decide what medication information they need to collect based on the services they provide. It is often important for clinicians to know what medications the individual is taking when planning care, treatment, or services, even in situations where medications are not used.

–Rationale for NPSG.03.06.01–
There is evidence that medication discrepancies can affect outcomes. Medication reconciliation is intended to identify and resolve discrepancies—it is a process of comparing the medications an individual is taking (or should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications. The types of information that clinicians use to
reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected in order to reconcile current and newly ordered medications and to safely prescribe medications in the future.

1. Obtain and/or update information on the medications the individual served is currently taking. This
information is documented in a list or other format that is useful to those who manage medications.
Note 1: The organization obtains the individual’s medication information during the first contact. The
information is updated when the individual’s medications change.
Note 2: Current medications include those taken at scheduled times and those taken on an as-needed
basis. See the Glossary for a definition of medications.
Note 3: It is often difficult to obtain complete information on current medications from the individual
served. A good faith effort to obtain this information from the individual and/or other sources will be
considered as meeting the intent of the EP.

2. Define the types of medication information (for example, name, dose, route, frequency, purpose) to be

collected in non-24-hour settings based on situations of individuals served and characteristics of
different settings.

3. For organizations that prescribe medications: Compare the medication information the individual

served brought to the organization with the medications ordered for the individual by the organization
in order to identify and resolve discrepancies.
Note: Discrepancies include omissions, duplications, contraindications, unclear information, and
changes. A qualified staff member, identified by the organization, does the comparison. (See also
HRM.01.06.01, EP 1)

4. For organizations that prescribe medications: Provide the individual served (or family as needed) with

written information on the medications the individual should be taking at the end of the encounter (for
example, name, dose, route, frequency, purpose).

5. For organizations that prescribe medications: Explain the importance of managing medication

information to the individual served.
Note: Examples include instructing the individual served to give a list to his or her primary care
physician; to update the information when medications are discontinued, doses are changed, or new
medications (including over-the-counter products) are added; and to carry medication information at all
times in the event of emergency situations. (For information on education of the individual served, refer
to Standard CTS.04.01.03.)

Reduce the risk of health care-associated infections.
Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and/or the current World Health Organization (WHO) hand hygiene guidelines.

Note: This standard applies only to organizations that provide physical care.

–Rationale for NPSG.07.01.01–
According to the Centers for Disease Control and Prevention, each year, millions of people acquire an infection while receiving care, treatment, or services in a health care organization. Consequently, health care–associated infections (HAIs) are a safety issue affecting all types of health care organizations. One of the most important ways to address HAIs is by improving the hand hygiene of health care staff. Compliance with the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines will reduce the transmission of infectious agents by staff to individuals served, thereby decreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, an organization should assess its compliance with the CDC and/or WHO guidelines through a comprehensive program that provides a hand hygiene policy, fosters a culture of hand hygiene, monitors compliance, and provides feedback.

Following safe hand hygiene practices is important in all organizations; however, the risk to individuals served increases when there is physical contact. In these situations, it is more important to follow formal hand hygiene guidelines. This requirement, therefore, applies only to organizations that provide physical care.

1. Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease
Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene
Note: This element of performance applies only to organizations that provide physical care.

2. Set goals for improving compliance with hand hygiene guidelines.
Note: This element of performance applies only to organizations that provide physical care.

3. Improve compliance with hand hygiene guidelines based on established goals.

Note: This element of performance applies only to organizations that provide physical care.

The organization identifies safety risks inherent in the population of the individuals it serves.
Reduce the risk for suicides.

–Rationale for NPSG.15.01.01–
Suicide of an individual served while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event. Identification of individuals at risk for suicide while under the care of or following discharge from a health care organization is an important step in protecting these at-risk individuals.

  1. The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide and takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).
    Note: Noninpatient behavioral health care and human services settings and unlocked inpatient units do not need to be ligature resistant. The expectation for these settings is to conduct a risk assessment to identify potential environmental hazards to individuals served, identify individuals who are at high risk for suicide, and take action to safeguard these individuals from the environmental risks (for example, continuous monitoring in a safe location while awaiting transfer to higher level of care and removing objects from the room that can be used for self-harm).

    2. Screen all individuals served for suicidal ideation using a validated screening tool.
    Note: The Joint Commission requires screening for suicidal ideation using a validated tool starting at age 12 and above.

    3. Use an evidence-based process to conduct a suicide assessment of individuals served who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.
    Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that simultaneously screens individuals served for suicidal ideation and assesses the severity of suicidal ideation.

    4. Document individuals’ overall level of risk for suicide and the plan to mitigate the risk for suicide.

    5. Follow written policies and procedures addressing the care of individuals served identified as at risk for suicide. At a minimum, these should include the following:
    – Training and competence assessment of staff who care for individuals served at risk for suicide
    – Guidelines for reassessment
    – Monitoring individuals served who are at high risk for suicide

    6. Follow written policies and procedures for counseling and follow-up care at discharge for individuals served identified as at risk for suicide.

    7. Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of individuals served at risk for suicide and take action as needed to improve compliance.

Although many of these goals are more applicable to hospital and community mental health settings rather than outpatient settings, they still provide a good starting point in looking at some of the potential patient risks of clinical practice. They also align with the ethical principles of psychologists, social workers, marriage and family therapists,
and mental health counselors.

The Joint Commission
defines a patient safety event as an event, incident, or condition that could have resulted or did result in harm to a patient. This may be the result of a defective system or process, a system breakdown, or human error. 

Sentinel Events

The Joint Commission terms the most acute medical errors, “sentinel events.”

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. 

It is important to note that the Joint Commission 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 dies from 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 errors that impact mental health professionals can be gleaned from malpractice data. Most malpractice suits are similar to medical errors; they involve situations in which treatment providers deviate in some way from accepted standards of practice and this deviation results in harm the clients. 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 possible malpractice claims:

• 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)
• Counter-suit 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 Joint Commission 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. These offenses can occur across many practice settings.
Some overall guidelines for preventing malpractice suits include understanding what constitutes a multiple relationship; setting clear guidelines up front; practicing therapist self-care; having appropriate malpractice coverage; and, staying connected (to professional organizations, colleagues, etc.).


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 that 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 are 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 promptly. The last to note is a hierarchical culture. When there is a fear of reprisal, it is difficult to raise issues for fear of being embarrassed or wrong.

Mental health professionals can avoid many medical errors. There is a direct
relationship between minimizing medical errors and maintaining professional competence. Competence is the ability to perform according to the standards of the profession. The issue of attaining and maintaining professional
competence has been a cornerstone focus of state credentialing boards and professional associations.

Despite the inclusion of competence in ethical codes for mental health practitioners, competence is a difficult concept to define. Competence includes formal education, professional training, supervised experience, the maintenance of ongoing training, practicing multicultural sensitivity, and conducting formative and summative, career-long assessments.

Competence implies that the treating clinician has the appropriate knowledge to
assess and diagnose and identify therapy goals and interventions within the context of the patient’s diagnosis and presenting issues. In addition to formulating goals, it is important to have the technical expertise to apply these interventions. At the most basic level, competence means that a clinician
would not treat a patient who presents with an issue with which they are unfamiliar or that requires specialized skills and knowledge. If a situation occurs within the course of an already established therapeutic relationship and that involves something that is outside the mental health professional’s areas of competence, he or she can choose to refer the patient to another provider or to seek these skills through reading and consultation. Often the former approach ensures a greater degree of safety for the client.

Clinicians need to be aware of their own personal problems that may interfere with their ability to provide care. These problems could include a divorce, a medical or psychological illness, or compassion fatigue. The latter is a condition common in treatment providers who work with trauma patients. The APA ethics code (2017a) requires psychologists that become aware of such issues to take steps to address the issues and concurrently limit or suspend professional duties.

The final area related to maintaining competence is a conscious effort on practitioners to further their education. Although continuing education requirements vary by state, it is important that mental health professionals keep up with changes in the field and within their scope of practice. Again, this helps to minimize error rates.


Informed Consent

Closely connected to the issue of competence is that of informed consent. 
Informed consent is “a process of communication and clarification” (Pope & Vasquez). At its heart, informed consent involves clarifying why clients seek treatment, their expectations of the therapy process, and their thoughts about what treatment will entail. The clinician also needs to discuss these factors with the client. As a result, mental health professionals can often refine their own understanding of the clients” presenting problems. Failure to obtain informed consent is in itself a medical error. Additionally, this process aids in reducing the possibility of errors in diagnosis and treatment planning. Further, informed consent is an essential aspect of establishing a professional relationship. When done effectively, it helps promote client autonomy by engaging in a collaborative process and reducing the likelihood of exploitation or harm.

Informed consent allows clients to make decisions about their treatment. An important factor in this is the concept of competence to consent to treatment. When a person is incompetent to consent to treatment, it means that a person’s judgment is so affected by his or her mental illness that the person lacks the capacity to make a well-reasoned and knowledgeable decision concerning their treatment. A comprehensive review of the issues connected with informed consent was written, focusing on the challenges and states that informed consent has three essential elements: voluntarism, information disclosure, and decisional capacity. Voluntarism is defined as “the ability of an individual to judge, freely, independently, and in the absence of coercion, what is good, right, and best subjected to his / her own situation, values, and prior history.” This is closely related to the idea of decisional capacity and can be challenging for clinicians to assess.

While informed consent provides clients with information to make decisions about the treatment process, the amount of information clinicians choose to share may vary from clinician to clinician and will be based on the client’s presenting issues. It is sometimes a challenge to provide appropriate informed consent and not to overwhelm an already harried client. The professional ethics codes provide minimum standards for what must be communicated to clients pertaining to informed consent for therapy, assessment, supervised treatment, and research. The codes require that clients are provided with information on the limits of confidentiality, fees, and the process of therapy. It also requires that clinicians clarify their roles with all clients and that trainees inform clients that they are being supervised. Medical errors may occur when the informed consent process is unclear.


Root Cause Analysis

The Joint Commission requires that all organizations investigate sentinel events, whether they are reported or not. Further, if the Joint Commission becomes aware of a sentinel event, the organization must submit an analysis or action plan within 45 business days of the event. Root Cause Analysis (RCA) is a retrospective approach to analyzing errors based on industrial psychology. As the name suggests, RCA 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 can be traced to identifiable causes. This allows the person or
the organization to make a mistake to ensure that it does not occur again.

The product of the RCA is an action plan that identifies the strategies that the organization intends to implement to reduce the risk of similar events occurring in the future.

The use of RCA tools generally reveal three types of causes:

• 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 a suicidal patient’s safety.

• Organizational causes – A system, process, or policy that mental health professionals 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.

The remainder of this learning material will use RCA to analyze clinical vignettes
depicting mental health medical errors.

Cultural Changes


Reducing 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 avoidable, and 24 percent were not avoidable. It is a common misconception that client safety can be improved by merely reminding health care personnel to be more careful. To correct the root of medical errors, instead of blaming an individual for an incident, the focus should be on reviewing the processes and factors surrounding 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 of 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 apparent that the process or system was error-prone. Hindsight bias is detrimental to accident analysis and understanding because it narrows 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 several methodological reasons why research in patient safety is particularly challenging. Many practices, particularly in counseling, cannot be double-blind studies because their use is evident to the participants. Also, capturing all relevant outcomes, including “near misses and 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 individuals’ technical work, instead of implementing prevention techniques as a means of crosschecking and monitoring progress is necessary to improve outcomes.


FMEA assumes that errors will occur in some situations and may even be likely to occur no matter how knowledgeable or careful people are. 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 essential counseling attributes; the way we talk and the words we use to describe an event help to shape treatment.

Whether communicating in a 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 of 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 an accident. For example, a client comes in to take the SASSI (Substance Abuse Subtle Screening Inventory), 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 occur in outpatient settings, and they happen in nursing homes. As professionals, we need to feel safe and respect our profession, sufficient 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 to 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 place blame.


I never understood why working in the mental health field, and we did not support each other better. We know how powerful words can be. Choose them carefully with the best 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 mistakes. 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 so.


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 critical factor in effective psychiatric treatment is patient involvement.

Uninvolved and uninformed 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 blaming the person involved, exploring 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 with 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, the staff is empowered. All staff is aligning on 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

What are the common types of medical errors that occur in the mental health industry?  Medical errors are mistakes made by mental health professionals within the normal work of their practice, which results in harm or potential harm to the patient or client. All errors constitute a failure in service delivery.  They all potentially have consequences for patients or clients at a time in which they are vulnerable. 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 when a client threatens self-harm.

In a seminal work on medical errors, Leape, Lawthers, Brennan, & Johnson (1993) lists the following four types of medical errors, all of which have implications for mental health professionals:

Diagnostic Errors:  inaccurate diagnosis of a medical/psychological condition, use of outmoded therapies, failure to act on a diagnosis),
Treatment Errors:  error in administering treatment, medication, or care that
is not indicated,
Preventive Errors:  inadequate monitoring or follow up, and
Other: communication errors, education errors, etc.

Medical errors are sometimes separated into two categories 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 occur when they fail to act in some way, such as a failure to report child abuse.

Understanding that the nature of counseling is largely reliant on client information is 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 practical ways of building rapport and asking difficult questions can be helpful. The use of other informants, with a release of information, can be useful. 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 most significant 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 requirements 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 the 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?



It is also important to consider the ethical mandate to maintain client confidentiality. Clients have the right to expect that disclosures made as part of the therapeutic process remain private. All mental health professionals ‘ ethics codes contain standards related to confidentiality. In addition to being an ethical issue, confidentiality is a therapeutic and legal issue. Breach of confidentiality is the leading cause of litigation. This is particularly concerning as confidentiality is central to developing a trusting and productive therapeutic relationship.

Violations of confidentiality are a common medical error. It is imperative to keep in mind the limits of confidentiality when disclosing information about a client. It is the clinician’s responsibility to define the degree of confidentiality that can be promised. It is required to have clients sign a written statement that includes information about limits to confidentiality. A client should understand in advance the circumstances under which the mental health professional is required to disclose information.

Such limits to client confidentiality include harm to self or others, legal requirements in cases involving a child or elder abuse and threats to others, and disclosures court-ordered as part of a legal proceeding. There are also specific limits based on treatment setting, such as working as a member of a treatment team, other coordination of care issues, insurance reviews, or supervisory situations.

With the exception of the conditions listed above, a provider cannot release a client’s mental health records unless the client has provided a valid written, signed, specific, and time-limited authorization allowing the clinician to do so. The “General Guidelines for Providers of Psychological Services” states that unless authorized by law, “Psychologists do not release confidential information, except with the written consent of the user involved, or his or her legal representative, guardian, or other holders of privilege.”

Minors have more limited rights in terms of confidentiality. Generally, parents
have the right to examine treatment records. Clinicians can request that parents give up this right or provide only general information.

With many clients paying for services using health insurance or EAP benefits, it is
also advisable for clinicians to discuss specific third-party requirements. These requirements can range from the need to share the dates of therapy and client diagnosis to more comprehensive clinical information. Some EAP organizations, for example, review clinician progress notes. Again, it is important to discuss these issues at the outset of therapy.

The term privilege is related to but not synonymous with confidentiality. Privilege refers to the right to withhold information from a court. Although the scope of privilege laws varies statewide, all states have laws that govern clinician/client communications. Privilege exists for the benefit of the client and belongs to the client. It is important to know that in most states, when a client introduces the idea that his or her own mental state is related to the content of the court proceedings, they cannot selectively choose what information will be shared with the court.

Given the various issues related to confidentiality, it is helpful to explore M.A. Fisher’s Confidentiality Limits.  This model is comprehensive and is an excellent summation of issues related to confidentiality. Fisher’s model has several components. The first is for the mental health professional to prepare for confidentiality concerns. This is essential and includes understanding their ethical responsibilities and client rights, learning the laws that affect the therapist’s abilities to protect confidential information, clarifying personal ethical positions about confidentiality and its legal limits, devising informed consent forms, and being prepared to discuss confidentiality in understandable language. Step two
is the actual informed consent process, which involves informing clients about limits on confidentiality and roles or potential conflicts of interest that might affect confidentiality.

The third component of Fisher’s plan is obtaining informed consent and being clear about when disclosures are required, disclosing without client consent only if legally unavoidable, informing clients adequately about content and implications of potential disclosures, and obtaining and documenting client consent before disclosing. Fisher also discusses responding ethically to legally-imposed disclosure situations. This involves notifying clients of pending legal requirements for disclosure and limiting disclosure of confidential information to the extent legally possible. Lastly, Fisher cautions providers to avoid the “avoidable” breaches of confidentiality, such as those that occur through poorly trained staff and record-keeping practices.

Mandatory Abuse Reporting

Another serious medical error is failing to report suspected abuse. Professionals working with children under the age of 18 and other vulnerable persons are considered mandated reporters. This means that they are required to report suspected child abuse.

All states have passed some form of mandatory child abuse and neglect reporting law in order to qualify for funding under the Child Abuse Prevention and Treatment Act (CAPTA). In addition to child abuse reporting laws, many states also have laws pertaining to mandatory reporting of disabled abuse and elder abuse. The laws pertaining to mental health providers working in private practice and institutional settings.

Many professionals are uncertain when a report is required, and practitioners vary in their understanding, opinions, and applications of these laws. In order to study this further, a survey of licensed psychologists was conducted.

Although they had knowledge of reporting laws, their performance on a knowledge measure suggested information deficits and a tendency to over-report. Legal considerations were the strongest factor that encouraged reporting. Opinions of the mandatory reporting laws were generally favorable, with some concerns about child protection systems and the impact of reporting on the therapeutic alliance. Using emergency room nurses as a sample, it has been found that knowledge about child abuse and perceived behavioral control were also significant influencing predictors of reporting intention.

Child abuse or neglect is defined as any recent act or failure to act that results in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child (usually a person under the age of 18, but a younger age may be specified in cases not involving sexual abuse) by a parent or caretaker who is responsible for the child’s welfare.

Sexual abuse is defined as employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person in engaging in, any sexually explicit conduct or any simulation of such conduct for the purpose of producing any visual depiction of such conduct; or rape, and in cases of the caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other forms of sexual exploitation of children, or incest with children.

One common question is how certain clinicians need to be in order to make a report.  State laws vary in terms of wording. For example, some statutes call for reporters to have a “reasonable suspicion” of abuse, while others require the reporter to “know or suspect.”

CAPTA requires states to enact legislation that provides for immunity from prosecution arising out of the reporting abuse or neglect. As with much of the child abuse literature, there is little consistency among professionals on when to report. A study of reporters in a community mental health setting indicated a lack of consensus in how community professionals interpret reasonable suspicion. This raised the question of whether more specific training is needed for this threshold to be understood, interpreted, and applied in a consistent manner. In most states, a person who reports suspected child abuse in “good faith” is immune from criminal and civil liability.


Duty To Warn

A topic that is related to abuse reporting is “Duty to Warn” or “Duty to Protect.”
“Duty to protect” laws require mental health providers to secure help for potential victims when a client discloses violent intentions. Failure to protect a potential victim is considered a medical error. In most states, a clinician must perform their duty to warn if a client or other identifiable person is in clear or imminent danger. Under conditions where there is proof of a risk to another person, the clinician must determine the degree of seriousness of the threat and notify the person in danger and those who are in a position to protect that person from injury. The following section will outline key considerations related to the duty to protect statutes.  

The case that established the current duty to warn laws was Tarasoff v. Regents of the University of California (1974). This case involved a University of California student, Prosenjit Poddar, who was a client at the university student counseling center. The treating clinician was concerned about Poddar’s obsessive attachment to a woman named Tatiana Tarasoff, who Poddar believed had rejected him. When Poddar disclosed to the clinician that he intended to purchase a gun, the clinician notified the police. The police made Poddar promise to stay away from Tarasoff; however, Poddar killed her two months later. Tarasoff’s parents sued the University of California. This case went to the
California Supreme Court, and resulted in the first of the duty to warn laws.

There is variability in the interpretation of the duty to warn cases; it is important for clinicians to be familiar with local laws. As with many of the errors previously discussed, there is often a question of when to warn. Within the scope of therapy, many express ill intentions towards another, and these often remain a fantasy. 

The mental health provider should always use the phrase “clear and imminent danger” as a guideline. Be cautioned that the threshold for the duty to warn or protect often rests beside the criteria permitting an exception to confidentiality, placing mental health professionals in a tenuous position. Mental health professionals can make reports to law enforcement agencies of client threats to their own welfare or other’s welfare

Suicides by Mental Health Patients


Should suicide be considered the result of medical errors? In some cases, it is.  For several years, it has been recognized that a significant means of suicide in acute psychiatric units have 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 are still the most common method among mental health inpatients. This is despite the fact that collapsible rails are now readily available. These are avoidable deaths.



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 inadequate training can lead to inaccurate diagnosing and treatment and a higher rate of human error. Insufficient staffing levels have been linked to an increase in 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 reduces the number of steps and handoffs.

2. Standardization, limit the variety of test instruments used, equipment, supplies, policies, and processes.

3. Reduce reliance on your memory. Make client notes immediately after sessions.

4. Use a 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 each file.

5. Eliminate look-a-likes and sound-a-likes, 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 improvement.

8. Increase communication feedback. Use feedback to modify or decrease error-prone behaviors.

9. Create a learning environment.

10. Teamwork. Use teams to promote both multidisciplinary perspectives in identification and solution.

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 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 allow us to prevent future harm by determining where the weak parts are in the care delivery system and then strengthening those areas.



An essential aspect of adequate 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 the 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 an important part in safe and effective care. Always evaluate 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, and 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.

edication errors can be broadly categorized into four 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. Please refer to the Medical Errors course in the nurse category for a more in-depth study of medication errors.


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.



Falls Prevention


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 risks for falls 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; noncompliance; incomplete histories, or lack of identification of falls risk.

Each year, one in every three adults age 65 and older falls.  Preventing or reducing the number of falls is a challenge in most healthcare settings, but the challenge is even greater in the mental health facilities and units. In the psychiatric or behavioral health setting, fall rates range from 4.5 to 25 falls per 1,000 patient days.

As noted above, many factors contribute to patient falls. These factors can be intrinsic, extrinsic, situational, or a combination.

  • Intrinsic factors associated with an increase in falls in a behavioral health unit include impaired cognition resulting from a chronic condition such as Alzheimer’s disease or an acute condition such as delirium. In addition, psychotropic medications and their adverse reactions may increase the likelihood of patient falls. Other intrinsic factors that may lead to falls include mobility, gait, vision, and balance disorders.
  • Extrinsic factors (environmental factors) that may contribute to patient falls in a behavioral health unit include a lack of support equipment, such as side rails when patients are getting into and out of bed, or a lack of durable medical equipment (DME), such as walkers, canes, and lifting devices. To add to these problems, mental health units have environmental restrictions to protect patients from harm.  For example, wired chair and bed alarms, side rails, and call systems with cords can endanger patients and staff. These issues can account for the lack of support equipment or DME.
  • Situational factors (factors related to activities) occur when patients are attempting to perform more than one task at a time, such as getting out of a wheelchair while conversing.


Patient safety

Further measures include tracking and trending fall data, including the day of the week, shift, time, location, assistive devices present or not present, diagnoses, and medications. Sharing the monthly and quarterly analyses with frontline staff, managers, and leaders of the organization helps programs apply human factors engineering concepts and a systems approach to fall prevention. To help prevent repeat falls, post-fall research assists in identifying what, when, where, who, and how. Barriers related to communication, staff training, patient education, environment, and equipment are included in each fall analysis.

To take a look at the organization as a whole, an annual retrospective review of all falls occurring during the year by an interdisciplinary group allows for input from subject matter experts to make system improvements. Team members may include nurses, physicians, pharmacists, and staff from rehabilitation services, prosthetics, and supply distribution.


  •  evidence-based practices in clinical practices improve patient safety. Some evidence-based practices include using an appropriate fall risk assessment tool, proper footwear, suitable signage, staff education, sitters, and safety rounding. All interventions used provide information that can be useful in identifying trends.

A fall risk assessment tool, including the Morse Fall Scale, should incorporate a list of drugs that place mental health patients at the highest risk for a fall. Facilities can modify their tool according to their patient population. The medications most often associated with falls include:

  • selective serotonin reuptake inhibitors
  • tricycliantipsychotic agents
  • benzodiazepines
  • antiepileptic drugs
  • class IA antiarrhythmic agents
  • antihypertensives.

As noted by Life Point 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 patient’s specific plan for safety, providing a safe environment including removing any hazards, providing adequate lighting, lock beds and wheelchairs, placing objects within reach of patients, and always ensuring that there is a method for patients to call for assistance.

Anticoagulants increase the risk of bleeding, injury, and death in patients who fall. Medication reconciliation that includes the type of anticoagulant, the duration of the anticoagulant therapy, and dietary restrictions should be considered in fall risk assessment. Report adverse drug reactions, such as abnormal bleeding, to the prescriber to adjust the dosage.

When executed and used properly, hourly rounding is an evidence-based practice that can reduce falls on any unit. In the case of the mental health and substance abuse patients, hourly rounding is based on patient needs identified after completion of the fall risk assessment. The American Psychiatric Nurses Association surveyed nurses about facilities’ standard minimum rounding practices and found that nurses at about 60% of psychiatric facilities are rounding every 15 minutes. Many falls can be prevented by combining hourly rounding with other interventions.

Technological innovations include virtual side rails that serve as monitors to alert staff to patients who are attempting to get out of bed without assistance. While these aren’t physical rails that might harm patients, they allow for immediate staff notification and rapid response to patients who may fall and need assistance.

Nursing Interventions

Assess a patient’s fall risk upon admission, change in status, transfer to another unit, and discharge from the facility. Implement an electronic fall risk assessment that will trigger a consult for rehabilitation services. Use sitters and assign high-risk patients to rooms closer to the nurses’ station to increase patients’ visibility.

  • Engage patients and their families in all components of a fall prevention program. Teach patients about their medications and potential adverse reactions.
  • Before assisting with mobility, evaluate the patient’s coordination and balance, then make sure the resources needed are available. Ensure that all movable equipment such as beds and wheelchairs are locked before moving the patient.
  • In the mental health environment, don’t leave equipment unattended that could be mobilized by the patient. For example, wheelchairs and bedside commodes can be used as weapons to harm patients and staff.
  • Before leaving a patient, be certain that lighting is adequate to prevent tripping.
  • Initiate a bowel and bladder program to decrease the patient’s attempts to get up without assistance due to urgency.
  • Apply appropriate nonskid footwear to help provide traction.
  • Assess and optimally manage pain.
  • Assess for orthostatic hypotension and teach the patient to change positions slowly.

Partnering with providers

Inform health providers of changes in a patient’s gait, posture, or spasticity. Performing medication reconciliation will help the provider and pharmacist prevent duplication of medications and drug interactions that can adversely affect patients. Be aware that providers’ medication regimen changes may lead to adverse reactions associated with polypharmacy and could contribute to a fall.

When mental health problems are coupled with decreased or limited mobility, patients are at high risk for falls. Initiating fall prevention measures is a collaborative effort.e The environment of psychiatric patients must be regulated, physical rehabilitation services should be initiated early to assess, evaluate, and manage gait issues. Having an electronic trigger to notify the healthcare provider when physical rehabilitation is needed closes the gap in communication. You initiate the trigger by completing a fall risk assessment.


Patients Rights and Protections


Communication from the initial consent to treat 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 with a release.


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, including 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 identify ways to prevent future errors.


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 emphasize how the client and their family can better and help their treatment. Encourage patients to ask questions about their treatment plans and goals to be sure they know.

Cultural Competence
The idea of competence also encompasses the need for mental health professionals to be culturally competent treatment providers. Legal and ethical mandates for mental health professionals stress the need for these professionals to respect and promote individuals’ and families’ welfare. All client behaviors are learned and displayed in a cultural context. Correct assessment, meaningful understanding, and appropriate intervention require awareness of the multicultural context.     

Although a full discussion of multicultural competence is not possible in this material alone, clinicians should familiarize themselves with issues related to multicultural competence.  Multicultural competence involves the possession of cultural knowledge and skills of a particular culture to deliver effective interventions to members of that culture. A culturally competent counselor

• Cultural awareness and beliefs: The provider is sensitive to her or his personal
values and biases and how these may influence perceptions of the client, the
client’s problem, and the counseling relationship.

• Cultural knowledge: The counselor has knowledge of the client’s culture,
worldview, and expectations for the counseling relationship.

• Cultural skills: The counselor has the ability to intervene in a manner that is
culturally sensitive and relevant.

Developing cultural competence can occur through the knowledge, professional skills, and personal attributes of the counselor.

  • Knowledge – consists of knowledge of the client’s culture, communication
    styles and help-seeking behaviors.
  • Professional skills – includes the application of specific techniques that will
    prove effective with diverse populations, the ability to discuss racial and
    ethnic issues and the ability to use resources on behalf of minority clients.
  • Personal attributes – perhaps the most important of the components
    includes a willingness to work with diverse populations and the ability to
    communicate genuine warmth and empathy.

There are a number of important facets to providing culturally competent care.
Among these are cultural self-assessment, engagement, multicultural assessment, cultural analysis, providing Psychopharmacol and testing using cultural thinking, fostering empowerment and culturally-specific healing, and multicultural consciousness (extending cultural competence beyond the clinical encounter).

In addition to providing culturally competent care, it is also important to consider competence with regard to other diverse groups. For example, clinicians need to be aware of issues connected with sexual diversity, socioeconomic diversity, and working with diverse age groups (see assessment section) and look at a closely related issue: provision of nondiscriminatory practices. Thus, medical errors connected with a lack of cultural competence can occur in client assessment, understanding, or intervention.

The APA (2017b) published Multicultural Guidelines: An Ecological Approach to Context, Identity, and Intersectionality. These ten guidelines can be easily applied to all mental health professionals who should:

Guideline 1 – recognize that identity and self-definition are fluid and complex, with a dynamic interaction between the two. Appreciate that intersectionality is shaped by the multiplicity of an individual’s social contexts.

Guideline 2 – recognize and understand that mental health
professionals hold attitudes and beliefs that can influence perceptions of and interactions with others and their clinical and empirical conceptualizations as cultural beings. Mental health professionals strive to move beyond conceptualizations rooted in categorical assumptions, biases, and/or formulations based on limited knowledge about individuals and their communities.

Guideline 3 – strive to understand the role of language and communication through engagement that is sensitive to the lived experience of the individual, couple, family, group, community, and/or organizations with whom they interact and to understand how they bring their own language and communication to these interactions.

Guideline 4 – endeavor to be aware of the role of the social and physical environment in the lives of clients, students, research participants, and/or consultees.

Guideline 5 – aspire to recognize and understand historical and contemporary experiences with power, privilege, and oppression. As such, mental health professionals seek to address institutional barriers and related inequities, disproportionalities, and disparities of law enforcement, administration of criminal justice, educational, mental health, and other systems as they seek to promote justice, human rights, and access to quality and equitable mental and behavioral health services.

Guideline 6 – seek to promote culturally adaptive interventions and advocacy within and across systems, including prevention, early intervention, and recovery.

Guideline 7 – examine the assumptions and practices of mental health as a profession within an international context, whether domestically or internationally based, and consider how this globalization has an impact on the psychologist’s self-definition, purpose, role, and function.

Guideline 8 – be aware of how developmental stages and life transitions intersect with the larger bio-sociocultural context, how identity evolves as a function of such intersections, and how these different socialization and maturation experiences influence worldview and identity.

Guideline 9 – aim to conduct culturally appropriate and informed research, teaching, supervision, consultation, assessment, interpretation, diagnosis, dissemination, and evaluation of efficacy as they address the first four levels of the Layered Ecological Model of the Multicultural Guidelines.

Guideline 10 – strive to take a strength-based approach when working with individuals, families, groups, communities, and organizations that seek to build resilience and decrease trauma within the sociocultural context.


Medication Concerns

Medication errors are associated with significant morbidity, and people with mental health problems may be particularly susceptible to medication errors due to various factors. Primary care has a key role in improving medication safety in this vulnerable population. The complexity of services, involving primary and secondary care and social services, and potential training issues may increase error rates, with physical medicines representing a particular risk. Service users may be cognitively impaired and fail to identify an error placing additional responsibilities on clinicians. The potential role of carers in error prevention and medication safety requires further elaboration. A potential lack of trust between service users and clinicians may impair honest communication about medication issues leading to errors. There is a need for detailed research within this field.

Research about medication errors in the mental health field is limited. In particular, very little is known about the incidence of error in non‐hospital settings or about the harm caused by it. Most of the current research relates to the inpatient environment, and there is an almost complete lack of data on the risks in the community – where most patients receive treatment. Factors such as impaired cognition, staff training issues, and a lack of trust potentially make people with mental health problems uniquely vulnerable to errors. Primary care has a key role in improving patient safety.

Evidence is available from other sources that psychotropic drugs cause a substantial number of adverse drug events. Some of these are preventable and might probably, therefore, be due to medication errors. 

In the USA, over half of the people with a mental health problem only receive treatment from primary care services.

General practitioners have been supported to develop a special interest in mental health. Pharmacists may have a significant role, particularly if a single pharmacy dispenses all the service user’s medication.  However, there may be barriers to supporting people with severe mental health problems within primary care, and clinicians may view it as a secondary care role beyond their expertise.  General practitioners may lack knowledge, skills, confidence, and formal training in mental health.

A lack of training and familiarity with certain classes of medicines may increase the risk of errors with this population.  However, whilst there is some evidence that psychotropics within primary care are associated with an increased risk of error again, robust data is currently lacking.  The possible increased risk associated with physical medicines when used within mental health organizations may be due to a lack of training. An important role for primary care is supporting the management of such physical medicines.

Frontline mental health staff linking with primary care, including social workers, occupational therapists, and support workers, may lack formal training in medicines management. Staff with limited knowledge could fail to act or offer inappropriate advice; a sore throat due to clozapine-induced neutropenia might not be viewed as significant, and only symptomatic treatment recommended. The increasing use of non‐medical prescribers, such as psychologists, may also increase the risk of medication errors, although currently, evidence of this is lacking. 

Patients intercept nearly a quarter of errors, but both medication and mental illness impair cognition and decision‐making facilities, and people with mental health problems may be less articulate and less likely to question a prescription, a change in medicine, whether monitoring is needed, or identify potential adverse events or a potential error.  Alternatively, if the patient does identify an error, this view may be ignored due to capacity concerns.  Impaired cognition and concerns about capacity occur most commonly during an acute phase. Medication is more likely to begin, and the patient’s care is more likely to be transferred across organizational boundaries, particularly during the acute phase, increasing the potential for errors. Therefore, patients are less able to prevent errors at precisely the time when errors are more likely to occur.

The following excerpt is from a study completed by Ian D. Maidment, Paul Lelliott, and Carol Paton and was published in the Quality and Safety in Healthcare in the UK.  The excerpt is a portion of the article and posted in its entirety.

This review shows that medication error in mental healthcare is a neglected aspect of research. In particular, there have been no systematic studies of patients living in the community. Therefore, the potential for mental health services to prevent harm and deaths from medication errors is unknown. Consistent with this, the issue is not high on the UK’s mental health policy agenda, where the overwhelming priority for risk management has been the prevention of suicide and homicide by people with mental illness. Prevention of suicide is a key government policy initiative, and concern about homicides by people with mental illness has been one of the main drivers of recent mental health service reform. Despite this emphasis, the potential for specialist mental health services to prevent suicide or homicide is quite modest. Each year, in England and Wales, there are about 1200 suicides and 50 homicides by people who have had recent contact with mental health services.  Perhaps one-fifth of these events could have been prevented by some action of the concerned mental health service.    This would equate to about 4.6 potentially avoidable deaths per million population each year.

The broader research literature on adverse events involving psychotropic drugs was not included in the systematic review because the studies do not identify which adverse drug events are preventable and hence would be classified as a medication error. However, they do show that psychotropic drugs cause substantial harm and suggest that mental health services might have greater potential to prevent deaths from adverse drug events than to prevent deaths from suicide and homicide. For example, the largest English study of its type estimated that adverse drug events caused 6.5% of all admissions and might account for about 6000 deaths each year. Antidepressants were implicated in 7% of these admissions.   The proportion of admissions due to psychotropics would certainly be higher if admissions because of intentional overdoses are included.

The remainder of this discussion considers what might be the priorities for future research on medication error in mental healthcare services and the potential of research to identify and quantify its causes. It draws on evidence about adverse drug events and inadequate prescribing practice. We suggest that some types of medication error might be more common in mental health services due to particular characteristics of the organization and delivery of mental health services and of the client group.

Communication difficulties in mental health services

One consequence of the move to community care is that modern mental health services are fragmented. In the UK, this has been accentuated by the recent NHS plan, which requires the establishment of specialist teams for home treatment, assertive outreach, and early intervention.   This has created numerous interfaces between primary and secondary care between hospital and community services and between different components of the community mental health service. Patients with severe and relapsing mental illness often cross these interfaces.

Problems of communication cause more than two-thirds of treatment errors in medical practice, and errors are likely when information is transferred across organizational boundaries.  In one study,  potentially harmful medication errors occurred in 24% of psychiatric admissions and in 18% of discharges. In another 41 of 58 medicines that mental health patients were taking were not consistently recorded in both the primary and secondary care records. In particular, secondary care records tend to omit non‐psychotropic drugs.   Junior doctors may take incomplete or inaccurate histories of medication on admission, partly because of reliance on a single source of information such as the general practitioner’s letter.   Primary care records may omit psychotropics, including medicines supplied by mental health services, such as clozapine, depot injections, and cholinesterase inhibitors. 

Role of the multi-professional team in medicine management

Two particular situations might warrant more systematic research on medication errors. The first is the frequent use of medication prescribed to be given “as required” at the discretion of nursing staff in mental health inpatient units. One study found that the quality of prescribing as required medication was considerably poorer than that of regular medication.  The potential risk is illustrated by a census of 3132 inpatients prescribed antipsychotics, which found that as required, medication sometimes gave nurses the option of giving doses above the recommended range.  The second situation is the role that members of community mental health teams have in monitoring medication in people with severe and enduring mental illness. These team members come from a wide range of disciplines, and many have received no training in the uses and potential side effects of psychotropic drugs. This increases the risk of unintentional harm in two ways: through inappropriate advice and through failure to act. An example of the first type of error is a team member encouraging a patient who has been non‐compliant with clozapine for a week to restart at the full dose, rather than reiterate the dosage, with the potential risk of adverse events such as marked postural hypotension. An example of the second type of error is a failure to recognize and act on potentially important physical health problems, such as a sore throat and fever in a patient receiving clozapine or increasing thirst and tiredness in a patient taking an antipsychotic drug.

Decision‐making errors in mental healthcare

Psychiatrists often fail to screen adequately for the adverse effects of psychotropic drugs. This includes screening for metabolic syndrome for patients prescribed atypical antipsychotics and for adverse effects and toxicity in patients prescribed lithium.  This may result in modifiable factors for premature death being untreated. Research on the cause of these failures to monitor for adverse drug reactions might inform the design of training interventions to deal with deficits in knowledge and systems that reduce the frequency of slips and lapses.

The problem of medication error related to inadequate prevention and management of adverse effects might be compounded by the frequency with which psychiatrists prescribe outside the product license.  Although such “off‐label” prescribing may sometimes be appropriate, it may increase the risk of harm through inadequate monitoring.   For example, safety alerts concerning drugs not licensed for psychiatric conditions, such as anticonvulsants prescribed as mood stabilizers, may not be directed to psychiatrists. Another example is the off‐label prescribing of high‐dose antipsychotics. This is associated with a higher incidence of adverse reactions to drugs and requires close monitoring. There is evidence that this often does not happen.

Two other situations, particularly in mental healthcare, are observed in which poor decision making may be a factor in preventable harm owing to adverse reactions to drugs. The first is the use of medication to manage acutely disturbed behavior. There is good evidence that monitoring of the patient is often inadequate after giving the medication despite the possible association between rapid tranquilization and death from a cardiovascular event.  The second situation is the prescription of toxic psychotropic drugs to people at risk of suicide. About 11% of deaths owing to drug overdoses involve antidepressants; this equates to 50 deaths each year. The prescription of less toxic antidepressants might prevent some of these deaths.

Factors related to patients

Patients with mental health problems may be less articulate and less likely to question a prescription, a change in the medication regimen, potential side effects, or whether monitoring is required. This, together with the fact that some patients might have reduced capacity, places additional responsibilities on mental healthcare staff. This applies particularly to mental health wards for older people, where many patients have dementia.

Poorly developed prescribing systems and pharmacy services

Many UK mental health services have poorly developed systems to aid communication and support safe medication management. There is also a lack of standardization so that clinicians who move between services are confronted with unfamiliar systems for prescribing, obtaining, handling, and administering medication.  Many inpatient units and community mental health teams have limited IT infrastructure, unintegrated, paper‐based record systems, little decision support for prescribing, and poor access to laboratories for monitoring.

Pharmacists are effective at detecting and preventing some serious prescribing errors.  In mental health services, the problems caused by poor prescribing systems are compounded by the inadequate staffing and organization of pharmacy services. Some mental health services have limited pharmacy infrastructure and so have limited awareness of or strategic capacity to improve medication management.  Poor staffing levels, inadequate training, lack of appropriate clinical expertise, and lone working without adequate clinical supervision are features of the service. In many mental health trusts, pharmacy services are contracted from acute care providers through service‐level agreements.  This can compound problems as the staff is employed by another organization whose systems of working may not prioritize mental health.



Organizations successful in improving patient safety have designed systems to protect against human shortcomings. They have made significant 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.


Similar philosophies must be embraced to improve safety in the modern health care system, and related changes must be made. It is the knowledge that both opportunity

and potential for improvement exists in the health care system that leads to a call for

rigorous research focused on preventable system errors and improved patient safety.



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