Medical Errors Updated for 2019

1. Medical ErrorsUpdated for 2019 As Required Per Florida Statute 456.13(7)

2. Purpose • The purpose of this course is to view the prevention of medical errors from the perspective of social workers, counselors, psychologists, family therapists and other behavioral health professionals.

3. Objectives • At the conclusion of this course, the participants will be able to: • Identify major causes of medical errors conducted by health professionals • Describe the effects of medical errors on patient safety and care from a mental health perspective • Describe methods to keep both clients and providers safe • Describe the process of root cause analysis and its role in the prevention of medical errors

4. Erring on the Side of Human Factors for Patient Safety (APA, 2007, Institute of Medicine Report) • On December 7, 1999, the Institute of Medicine (IOM) issued a report entitled "To Err is Human: Building a Safer Health System," • This report identified medical error as the third leading cause of death in the United States.

5. 3rd Leading Cause of Death • Since that initial report numerous studies have reported similar findings for years • Makary, 2016 • Appleby, 2015 • Amy et al, 2014 • James, 2013 • Just to cite a few

6. Views on Medical Errors • In a survey conducted by the Harvard School of Public Health of both Drs (n=831) and the public (N=1803) reported their personal experiences with medical errors (Blendon, R. et al., 2002)

7. Views on Medical Errors • 35% of Drs & 42% of the public • had experienced an error in their own care or that of a family member. • 18% of Drs & 24% of the public • reported that an error had serious health consequences,

8. Views on Medical Errors • 7% of Drs & 10% of the public • reported that an error lead to death • 6% of Drs & 11% of the public • reported that an error lead to long term disability

9. Medical Errors • Clearly this is a common problem and must be addressed

10. Medical Errors • Medicine has traditionally treated errors as failings on the part of individual providers, reflecting inadequate knowledge or skill.

11. Medical Errors • The systems approach, by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems. (AHRQ, 2012)

12. Causes of Medical Error • According Berwick from the Centers for Medicare & Medicaid • “The leading cause of medical mistakes is the increasing complexity of healthcare.”

13. Complexity of Medical Error and Injury Issues (APA, 2007) • Medical error is usually the result of a confluence of circumstances rather than one person simply making a mistake.

14. Complexity of Medical Error and Injury Issues (APA, 2007) • Therefore reducing medical error and injury cannot be accomplished merely by identifying and punishing individuals who have made errors.

15. Complexity of Medical Error and Injury Issues (APA, 2007) • Instead, most experts believe that reduction depends on addressing error systemically.

16. Agency for Healthcare Research and Quality • Today, while progress has been made, it has not spread evenly throughout the Nation's health care system.

17. Agency for Healthcare Research and Quality • AHRQ started the process of building the foundation to better understand patient safety challenges and how effective solutions could be implemented.

18. Agency for Healthcare Research and Quality • Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality.

19. Agency for Healthcare Research and Quality • To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient and Family Engagement in Hospital Quality and Safety,

20. Strategies from the Guide to Patient and Family Engagement • Encourage patients and family members to participate as advisors. • Promote better communication among patients, family members, and health care professionals from the point of admission.

21. Strategies from the Guide to Patient and Family Engagement • Implement safe continuity of care by keeping the patient and family informed • Engage patients and families in discharge planning throughout . . .

22. Key Terms Medical Error: a preventable adverse event or near miss due to the failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim

23. Key Terms Adverse Event: unintended patient harm caused by medical management rather than by a disease process, which results in a prolonged stay, morbidity or mortality

24. Key Terms Near Miss: an error or mishap that had the potential to cause patient harm, but did not, either by chance or thanks to timely intervention

25. Medical Errors • To better understand medical errors – we first need to categorize them

26. Medical Errors • Medical errors can be broken down into 2 types • Acts of commission • Acts of omission

27. Medical Errors • Acts of commission • These are things that you DO which are mistakes • Examples of acts of commission would include: • Incorrect diagnosis • Sexual misconduct

28. Medical Errors • Acts of omission • These are things that you FAIL TO DO that are expected • Examples of acts of omission would include: • Failure to keep adequate records • Failure to report child abuse

29. Medical Errors • Both acts of commission and omission are judged against prevailing standards of practice for your profession

30. Potential Errors within a Psychological Setting • Florida Board of Psychology finds each of these errors so serious, they are specifically mandated as content within this course . . .

31. Potential Errors within a Psychological Setting • Inadequate assessment of suicide risk • Failure to comply with mandatory abuse reporting laws • Failure to detect medical conditions presenting as a psychological disorder

32. Inadequate Assessment Of Suicide Risk • This may be the worst case scenario for medical errors • Risk of death is high • Professional responsibility to assess risk exists • Use Florida Baker Act for imminent risk • When in doubt - Consult !

33. Failure To Comply With Mandatory Abuse Reporting Laws • Psychologists, social workers and other mental health professionals are trained to identify child and elder abuse • Although other professionals are required to report suspected abuse, clearly those in mental health understand the importance • When in doubt, report

34. Failure To Detect Medical Conditions Presenting As A Psychological Disorder • Many psychological disorders present with physical symptoms that are associated with medical conditions • First rule out all medical conditions by referring to the appropriate medical specialty

35. Failure To Detect Medical Conditions Presenting As A Psychological Disorder • For example • if a client presents with heart palpitations and shallow breathing, treatment for panic attacks is only appropriate after it is determined that they do not have a heart condition

36. Failure To Detect Medical Conditions Presenting As A Psychological Disorder • For example • if a client presents with trouble sleeping, loss of interest and weight loss a diagnosis of depression is only appropriate if they do not have a medical illness causing these symptoms

37. Medical Errors in Behavioral Health • Failure to fully disclose limits of confidentiality • Misdiagnosis • Failure to refer elsewhere • Mistakes in documentation • Inadequate records

38. Medical Errors in Behavioral Health • Failure to use best practices • Empirically sound treatment • Failure to use supervision • Failure to make adequate progress • Failure to terminate when indicated

39. New Findings Researchers have identified cognitive decline in the client and the misdiagnosis of this as a source of medical errors The relationship between clients and their healthcare workers is an exchange between unequal partners Van Cott, 2018

40. New Findings Fatigue has also been linked error in healthcare settings This work focused on shift work, sleep loss, and circadian rhythms But it seems logical that this would also apply to other workers who are fatigued Van Cott, 2018

41. New Findings A recent study on patient safety in mental health units (VHA) Searched reported adverse events that occurred on an inpatient mental health unit between 1/1/15 and 12/31/16 Mills, Watts, Shiner & Hemphill, 2018

42. New Findings Found 87 root cause analysis (RCA) reports and 9780 safety reports Safety reports were coded for type of event and RCAs were further coded for underlying causes and severity Mills, Watts, Shiner & Hemphill, 2018

43. New Findings • Of 87 RCA reports there were • 31 suicide attempts • 16 elopements • 10 assaults • 8 events w/ hazardous items on unit • 7 falls • 6 unexpected deaths • 3 overdoses and • 6 cases coded as “other” Mills, Watts, Shiner & Hemphill, 2018

44. New Findings • For the 9,780 safety reports, the most common events (in order) were • Falls • Medication events • Verbal assaults • Physical assault • Medical problems and • Hazardous items on the unit Mills, Watts, Shiner & Hemphill, 2018

45. Worst Case Scenarios • Death of a Client - Could be due to either acts of commission or omission • Medical errors that result in • Suicide • Homicide

46. Suicidal Clients • Medical errors with suicidal clients • Failure to properly diagnose • Failure to properly treat • Failure to Baker Act when appropriate • Improper use of contracts

47. Homicidal / Violent Clients • Medical errors with homicidal or violent clients • Failure to diagnose accurately • Failure to properly treat • Failure to Baker Act appropriately • Failure to exercise Duty to Warn • Improper use of contracts • Failure to separate violent clients

48. Homicidal / Violent Clients • Duty to Warn • Duty to Protect - • In Florida this usually means Baker Act • Tarasoff applies in most states – there is some disagreement about the application of duty to warn in Florida

49. Prevention And Analysis • Root-cause analysis • Error reduction & prevention • Patient Safety • Practice Guidelines

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