Study Points

Medical Error Prevention for Mental Health Professionals

Course #71312 - $15 • 2 Hours/Credits

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. Medical errors are caused by what two types of failures?

    DEFINING "MEDICAL ERROR"

    The IOM Committee on Quality of Healthcare in America defines error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim" [1]. It is important to note that medical errors are not defined as intentional acts of wrongdoing and that not all medical errors rise to the level of medical malpractice or negligence. Errors depend on two kinds of failures: either the correct action does not proceed as intended, which is described as an "error of execution," or the original intended action is not correct, which is described as an "error of planning" [1]. A medical error can occur at any stage in the process of providing patient care, from diagnosis to treatment, and even while providing preventative care. Not all errors will result in harm to the patient. Medical errors that do result in injury are sometimes called preventable adverse events or sentinel events. These events are considered "sentinel" because they signal the need for immediate investigation and response [4].

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  2. The IOM Committee on Quality of Healthcare in America defines sentinel events as events

    DEFINING "MEDICAL ERROR"

    Preventable adverse events or sentinel events are defined as events that cause an injury to a patient as a result of inaction on the part of the healthcare provider or as a result of an action/intervention whereby the injury cannot reasonably be attributed to the patient's underlying medical condition [1]. For example, if a patient has a surgical procedure and dies postoperatively from pneumonia, the patient has suffered an adverse event. But was that adverse event preventable? Was it caused by medical intervention or inaction? The specific facts of the case must be analyzed to determine whether the patient acquired pneumonia as a result of poor handwashing techniques of the medical staff (i.e., an error of execution), which would indicate a preventable adverse event, or whether the patient acquired pneumonia because of age and comorbidities, which would indicate a nonpreventable adverse event.

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  3. What percentage of sentinel events occur in psychiatric hospitals or behavioral health facilities?

    ROOT CAUSE ANALYSIS PROCESS

    The Joint Commission is a national organization with a mission to improve the quality of care provided at healthcare institutions in the United States. It accomplishes this mission by providing accredited status to healthcare facilities. Accreditors play an important role in encouraging and supporting actions within healthcare organizations by holding them accountable for ensuring a safe environment for patients. Healthcare organizations should actively engage in a cooperative relationship with the Joint Commission through this accreditation process and participate in the process to reduce risk and facilitate desired outcomes of care. Based on data from The Joint Commission, 84% of sentinel events occur in hospitals, emergency departments, or ambulatory care centers and 13% of sentinel events occur in psychiatric hospitals or behavioral health facilities [46].

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  4. Where do most inpatient suicides occur?

    ERROR REDUCTION AND PREVENTION

    It is possible that the event with the greatest emotional impact on mental health professionals (and patients' families) is patient suicide. In general, the suicide rate is increasing, with a nearly 30% higher rate in 2016 compared with 1999 [43]. According to a 2010 Joint Commission Sentinel Event Alert, 75% of inpatient suicides occurred in psychiatric hospitals or behavioral health units of general hospitals [13]. The next greatest number occurred in surgical, intensive care, telemetry, or oncology units (14.25%); emergency departments (8%); and home care, rehabilitation units, and long-term or residential care facilities (2.5%). General hospitals are inherently less safe for suicidal patients than psychiatric hospitals or units, as they offer the patient more time alone and a number of potential suicide options (e.g., jumping, intentional drug overdose, cutting with a sharp object, hanging, strangulation) and means (e.g., tubing, bandages, plastic bags) that are designed out of psychiatric settings[13]. Another study reported 73.9% of hospital inpatient suicides in 2014–2015 happened during psychiatric treatment [48].

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  5. Several reasons for inadequate suicide risk assessments have been identified, including all of the following, EXCEPT:

    ERROR REDUCTION AND PREVENTION

    There are many suicide risk assessment tools for use by health and/or mental health professionals but few have been tested empirically. If and when they are used, all too often an assessment tool is insufficient in preventing suicide. A thorough assessment by a trained mental health professional is often the best choice, but even these professionals are not infallible. Of those who die from suicide, 20% have had contact with a mental health provider in the last month[43]. Many reasons have been identified for inadequate professional assessments or lack thereof [16]:

    • Suicide risk assessment training was never provided to the mental health professional, physician, or nurse.

    • The risk of suicide is minimized or overlooked by the professional due to personal anxiety related to suicide in general.

    • The professional has a fear of documenting thought processes because those actions could come under scrutiny in a malpractice suit.

    • Risk assessment is performed but not documented.

    • The task of suicide risk assessment is delegated to another professional who is incapable of performing an adequate assessment or who does not complete the task.

    • Suicide risk assessment is simply not indicated.

    • A systematic suicide risk assessment is never performed.

    • The professional is reluctant to assess suicide risk due to excessive false positives.

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  6. Which of the following statements regarding mandatory abuse reporting is TRUE?

    ERROR REDUCTION AND PREVENTION

    In Florida, as in other states, workers in many occupations are designated as "professionally mandated reporters of abuse," including teachers, nurses, physicians, and law enforcement officials [22]. Social workers, psychologists, and all mental health professionals are included among those who are required to report abuse, neglect, abandonment, and exploitation of children and adults. Additionally, suspected maltreatment is to be reported.

    There were about 674,000 unique cases of child abuse in the United States in 2017 resulting in approximately 1,720 deaths[23]. The vast majority of perpetrators of abuse were parents or legal guardians. More than 65% of the referrals of abuse are generated by a mandated professional, including social services personnel (11.7%), medical personnel (9.6%), and mental health personnel (5.7%); children very seldom report abuse themselves [23]. The percentage of reports generated by professionals remained stable between 2009 and 2017.

    Only about 17% of all reports of child abuse or suspected child abuse result in a substantiation or indication of actual maltreatment according to state law [23]. However, this should not discourage the professional from intervening. It is never punishable to submit a report in good faith; furthermore, all reports are confidential (except among protective services personnel) until indicated in a judicial proceeding [22]. In addition to breaching the ethical duty to protect clients from harm (and, subsequently, the professional consequences of this ethics violation), there are legal consequences for those who fail to comply with mandatory abuse reporting requirements. Diligent reporting and documenting of abuse better protects professionals from legal action resulting from inaction.

    Adult abuse encompasses self-abuse, domestic abuse, and abuse/exploitation by caregiver(s) of a vulnerable adult [22]. Exploitation refers to the misuse of moneys, taking or selling of property, the inappropriate use of guardianship/power of attorney, and the failure to use the vulnerable adult's funds for their care. A vulnerable adult is defined in Florida as an individual 18 years of age or older with "mental, emotional, long-term physical or developmental disability/dysfunction, brain damage, or the infirmities of aging" that prevent him or her from performing activities of daily living or providing for his or her own care [22]. Vulnerable adults and children are abused at a rate between 4 and 10 times greater than that of the general population and are themselves less likely to report abuse due to a variety of fears, including not being believed, reprisals, and caretaker abandonment [24]. Mental health professionals are often the individuals to whom the abuse is reported. With the aforementioned statistics and somewhat unique fears in mind, it is reasonable that a slightly higher index of suspicion be employed when working with this cohort.

    Emotional changes or suspicious injuries that are noticed in adult clients should be documented and reported. Marks and bruises in various stages of healing should be noted, especially those that resemble objects such as belts or electrical cords or those that reoccur regularly; cigar/cigarette burns; burns in the shape of an object (e.g., clothes iron); missing clumps of hair; marks from being tied down; and other injuries with no reasonable explanation [25]. Other signs of abuse include recurrent poor hygiene among those in the care of others, medical conditions left untreated, food hoarding, age-inappropriate sexual behavior/knowledge of sex, unexplained fear of persons/places, unaccounted for injury or disease of the genitals. Psychologic abuse may be harder to detect, but in some cases there are physical manifestations of psychologic abuse. Studies of the long-term physical effects of intimate partner violence or child abuse have found an increased risk of asthma, chronic pain, sexually transmitted infections, stomach ulcers, liver disease, and high blood pressure among victims [6,32].

    Compliance with abuse reporting laws is not optional, and reporting suspected abuse to a supervisor does not satisfy this requirement[22]. Abuse must be reported to the Florida Abuse Hotline by telephone (1-800-962-2873 or TTY 1-800-955-8771), by fax (1-800-914-0004), or online (https://reportabuse.dcf.state.fl.us) when knowledge of abuse or suspected reasonable cause exists. Telephone is the preferred contact method and should always be used in emergency situations. It is up to the Florida Department of Children and Families counselors to determine if the report meets the legal requirements for further action[22]. If a counselor refuses the report, a supervisor can be requested for further discussion.

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  7. If a Florida Abuse Hotline counselor refuses an abuse report but the reporter disagrees with the decision, he or she should

    ERROR REDUCTION AND PREVENTION

    Compliance with abuse reporting laws is not optional, and reporting suspected abuse to a supervisor does not satisfy this requirement[22]. Abuse must be reported to the Florida Abuse Hotline by telephone (1-800-962-2873 or TTY 1-800-955-8771), by fax (1-800-914-0004), or online (https://reportabuse.dcf.state.fl.us) when knowledge of abuse or suspected reasonable cause exists. Telephone is the preferred contact method and should always be used in emergency situations. It is up to the Florida Department of Children and Families counselors to determine if the report meets the legal requirements for further action[22]. If a counselor refuses the report, a supervisor can be requested for further discussion.

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  8. On average, medical conditions are the actual cause of what percentage of psychiatric admissions?

    ERROR REDUCTION AND PREVENTION

    In one study, 3% of psychiatric admissions are actually due to a medical condition; this number is likely higher for older individuals[28]. For example, elderly patients or patients with intellectual disabilities with various infections often present to emergency or urgent care facilities with no other symptoms other than psychosis due to delirium; these infections may be initially overlooked as the healthcare team focuses on the psychologic symptoms [29,47]. Urinary tract infections and pneumonia are the most frequent causes of sudden change in mental status in elderly patients, but these patients are often initially diagnosed with dementia based on their age[30]. Other possible causes include electrolyte imbalances, thyroid dysfunction, organ failure, and medications.

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  9. Which of the following is the most frequent cause of sudden change in mental status in elderly patients?

    ERROR REDUCTION AND PREVENTION

    In one study, 3% of psychiatric admissions are actually due to a medical condition; this number is likely higher for older individuals[28]. For example, elderly patients or patients with intellectual disabilities with various infections often present to emergency or urgent care facilities with no other symptoms other than psychosis due to delirium; these infections may be initially overlooked as the healthcare team focuses on the psychologic symptoms [29,47]. Urinary tract infections and pneumonia are the most frequent causes of sudden change in mental status in elderly patients, but these patients are often initially diagnosed with dementia based on their age[30]. Other possible causes include electrolyte imbalances, thyroid dysfunction, organ failure, and medications.

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  10. One of the more successful interventions for post-traumatic stress and anxiety disorders following an experience with a medical error is

    PSYCHOLOGIC CONSEQUENCES OF MEDICAL ERRORS

    It is important that patients and professionals understand that risk and trust are a part of everyday life. It is necessary for clients to regain trust or self-trust and learn to rethink in a more complex way. Cognitive-behavioral therapy has been shown to be one of the more successful methods of reducing post-traumatic stress or anxiety and may be useful for these clients [38,39].

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.