Medical Errors. As Required Per Florida Statute (7)

Transcription

1 Medical Errors As Required Per Florida Statute (7) 1

2 Florida Statute (7) The board shall require the completion of a 2-hour course relating to prevention of medical errors as part of the licensure and renewal process. 2

3 Florida Statute (7) The 2-hour course shall count towards the total number of continuing education hours required for the profession. 3

4 Florida Statute (7) The course shall be approved by the board or department, as appropriate, and shall include a study of rootcause analysis, error reduction and prevention, and patient safety. 4

5 Purpose The purpose of this course is to view the prevention of medical errors and includes the perspective of mental health professionals, psychologists and dieticians. 5

6 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 and mental errors on patient safety and care. Identify approaches to prevent and correct errors. Describe methods to keep both clients and providers safe. 6

7 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) dropped a bomb during what would have been a quiet congressional recess. The "bomb" was a report entitled "To Err is Human: Building a Safer Health System," identifying medical error as the third leading cause of death in the United States. 7

8 Medical Errors Medicine has traditionally treated errors as failings on the part of individual providers, reflecting inadequate knowledge or skill. The systems approach, by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems. (AHRQ, 2012) 8

9 Complexity of Medical Error and Injury Issues (APA, 2007) Medical error is usually the result of a confluence of circumstances rather than simply one person making a mistake, so reducing medical error and injury cannot be accomplished simply by identifying and punishing individuals who have made errors. 9

10 Complexity of Medical Error and Injury Issues (APA, 2007) Instead, most experts believe that reduction depends on addressing error systemically. 10

11 Complexity of Medical Error and Injury Issues (APA, 2007) That is, it depends on understanding the relationship between proximal and distal causes of error and altering the causal stream, so that errors are not facilitated. 11

12 Complexity of Medical Error and Injury Issues (APA, 2007) Reduction of error and injury also depend on understanding success, since medical-setting studies show that far more accidents are waiting to happen than actually happen. 12

13 Complexity of Medical Error and Injury Issues (APA, 2007) Clearly, error in medicine (as in any complex system) involves understanding how people perform, how people think, how people communicate with one another, and how people interact with technology in complex organizational systems. 13

14 Complexity of Medical Error and Injury Issues (APA, 2007) So a systems approach to understanding both safety and error involves multiple domains within scientific psychology. 14

15 Medical Errors This systems approach to reducing error makes sense to all of us in the fields of social work, mental health and psychology. 15

16 Medical Errors It fits well with how we typically conceptualize problems. 16

17 Medical Errors Medical errors can be broken down into 2 types Acts of commission Acts of omission 17

18 Acts of commission Medical Errors These are things that you DO which are mistakes Examples of acts of commission would include: Incorrect diagnosis Sexual misconduct 18

19 Acts of omission Medical Errors 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 19

20 Medical Errors Both acts of commission and omission are judged against prevailing standards of practice for your profession 20

21 Simple steps Medical Errors Become a member of your professional organization Read board findings / minutes Keep your professional skills current Use supervision regularly These steps can make you aware of the mistakes of others in your field and help you avoid them 21

22 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... 22

23 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 23

24 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! 24

25 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 suspicions 25

26 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 26

27 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 27

28 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 28

29 Worst Case Scenarios Death of a Client - Could be due to either acts of commission or omission Medical errors that result in Suicide Homicide 29

30 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 30

31 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 31

32 Homicidal / Violent Clients Duty to Warn Duty to Protect - In Florida this usually means Baker Act Tarasoff applies 32

33 Practice Guidelines Exercise proper professional care This includes: Referring out when you do not have the expertise to treat effectively Seeking supervision and consultation Updating your own clinical skills to keep up with scientific advances in the field 33

34 Practice Guidelines Consult when necessary It is good practice to consult with an experienced clinician regularly and often Discuss difficult cases Seek advice / expertise No one can be an expert at everything 34

35 Practice Guidelines Take careful histories and advise clients: Fully informed consent Limits of confidentiality Have signed forms on file Rights and responsibilities 35

36 Practice Guidelines Document all interventions Inadequate records can easily result in medical errors Failure to maintain sufficient client records can lead to difficulty with the board Client record requirements will be reviewed in detail later in this presentation 36

37 Practice Guidelines Create and follow a clear protocol regarding duty to warn and contingency plans Develop protocols for all high risk situations that you are able to predict in advance These protocols will vary from agency to agency and population to population 37

38 Practice Guidelines Develop risk management procedures If you have difficulty generating procedures, read practice guidelines for most situations are easy to find from your professional organization It is easier and safer to develop these procedures when there is no crisis to be resolved immediately 38

39 Expressed & Informed Consent Expressed and Informed Consent is: - Consent voluntarily given in writing, by a competent person, after sufficient explanation and disclosure of the subject matter involved to enable the person to make a knowing and willful decision without any element of force, fraud, deceit, duress, or other form of constraint or coercion. 39

40 Expressed & Informed Consent What does incompetent to consent to treatment mean? - A person s judgment is so affected by his or her mental illness that the person lacks the capacity to make a well-reasoned, willful, and knowing decision concerning his or her medical or mental health treatment 40

41 Psychotherapist Client Relationship This relationship is established once services, psychotherapy, counseling, assessment or treatment are rendered 41

42 Psychotherapist Client Relationship A contract, scheduling of appointments, or payment of a fee are not necessary conditions to establish that a relationship exists 42

43 Psychotherapist Client Relationship This relationship once established is deemed to continue for a minimum of 2 years after the termination of psychotherapy or the last date of professional contact with the client 43

44 Client Records Requirements Psychological Report, Psychosocial or Assessment Treatment Plans Progress Notes Discharge Summaries 44

45 Client Records Requirements Basic client information Treatment or evaluation session dates, including cancellations and phone contacts Diagnosis, if applicable 45

46 Client Records Requirements Interventions and results Client s consent documents, releases, and consultations Financial transactions 46

47 Client Records Requirements For social workers, mental health counselors and marriage and family therapists Records must be kept for 7 years after termination 47

48 Client Records Requirements Psychologists must keep all records for 3 years after 3 years, they may keep a summary of the record. The summary must be kept for 7 years after termination 48

49 Confidentiality, Record Keeping, Mandatory Reporting Confidentiality Waivers refer to Ch Confidentiality has its limits Clients must be fully informed to make informed choices Documentation must be thorough 49

50 Limits to Confidentiality Duty to warn Mandatory reporting Child / Elder abuse and neglect Multidisciplinary teams Supervision 50

51 Limits to Confidentiality HIV patients Minors records Group counseling Health plans information gathering 51

52 Mandatory Reporting Children, Elderly, Disabled Adults Abuse Neglect Abandonment Death For some disciplines (medical) Threats to public health (STDs) 52

53 Mandatory Reporting Chapter Chapter requires mandatory reporting of child abuse, abandonment, or neglect; mandatory reports of death; central abuse hotline 53

54 Adult Protective Services Act Mandatory reporting of abuse, neglect, or exploitation of vulnerable adults; mandatory reports of death. 54

55 Adult Protective Services Act Protective investigations of cases of abuse, neglect, or exploitation of vulnerable adults; transmittal of records to state attorney. 55

56 Title XXIX Chapter 394 The Florida Mental Health Act AKA The Baker Act 56

57 Mental Illness Definition [F.S (18)] Impairment of the emotional processes that exercise conscious control of one s actions or of the ability to perceive or understand reality, which impairment substantially interferes with a person s ability to meet the ordinary demands of living, regardless of etiology. 57

58 Mental Illness Definition [F.S (18)] For the purposes of this part, the term does not include retardation or developmental disability as defined in Chapter 393, intoxication, or conditions manifested only by antisocial behavior or substance abuse impairment. 58

59 Disciplinary Guidelines, Board Please refer to F.S. 490 Orders Review of guidelines, probable cause, title violations, violations of descriptive terms of service, minor violations, citations, sexual misconduct, terms of probation, mediation offenses, and supervision by disciplined practitioner. 59

60 Defined by Chapter 64 Sexual Misconduct It is sexual misconduct for a psychotherapist to engage, attempt to engage, or offer to engage a client in sexual behavior, or any behavior, whether verbal or physical which is intended to be sexually arousing including kissing, sexual intercourse, (etc). 60

61 Prevention And Analysis Root-cause analysis Error reduction & prevention Patient Safety 61

62 Root Cause Analysis Root cause analysis helps identify what, how and why something happened, thus preventing recurrence. 62

63 Root Cause Analysis Root causes Are underlying Are reasonably identifiable Can be controlled by management Allow for generation of recommendations 63

64 Root Cause Analysis The process involves data collection, cause charting, root cause identification Recommendation generation Implementation 64

65 Root Cause Analysis Example Understanding why an event occurred is the key to developing effective recommendations. 65

66 Root Cause Analysis Example Lets suppose that you have a practice that includes a lot of patients with the diagnosis of Major Depression 66

67 Root Cause Analysis Example Now lets suppose that you do your own billing and that it requires that you enter the DSM diagnostic code 67

68 Root Cause Analysis Example What if you enter the code incorrectly? 68

69 Root Cause Analysis Example And based on the DSM diagnostic code, the client s claim for insurance is denied. 69

70 Root Cause Analysis Example Because insurance companies often deny claims for mental health. You assume that they will not pay for treatment. 70

71 Root Cause Analysis Example You inform the client that their insurance claim was denied. They report that they are sure that they have coverage for mental health services. 71

72 Root Cause Analysis Example Some possible recommendations might be... 72

73 Root Cause Analysis Example Private pay for treatment Use a short term treatment plan Refer to a mental health center for treatment 73

74 Root Cause Analysis Example But in reality, it was a medical error that is the problem. And a root cause analysis can help to determine the source of the error. 74

75 Root Cause Analysis Example Root Cause Analysis theory states that generally, mistakes do not just happen but can be traced to some well-defined causes. 75

76 Root Cause Analysis Another Example Identifying that poor insurance coverage is the problem does not help. Mainly because nothing can be done about a client s insurance coverage. 76

77 Root Cause Analysis Root cause analysis investigates to determine why an error took place and what the organization can do to prevent recurrence. 77

78 Error Reduction and Prevention Identifying root causes is the key to preventing similar recurrences. If you are able to determine that the source of the problem is that the diagnostic code was entered incorrectly you solve the problem. 78

79 Error Reduction and Prevention An added benefit of an effective root cause analysis is that, over time, the root causes identified across the population of occurrences can be used to target major opportunities for prevention and improvement. 79

80 Error Reduction and Prevention In this example, you can establish a procedure for checking the DSM diagnostic code before submitting an insurance claim. 80

81 Error Reduction and Prevention When this procedure is applied to all of your clients, insurance claims are less likely to be denied when they should be paid. 81

82 Patient Safety First, Do no harm Act within your scope Follow Code of Ethics Seek supervision Contract when appropriate 82

83 Checklists A checklist is an algorithmic listing of actions to be performed in a given clinical setting, the goal being to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering and have played a major role in some of the most significant successes achieved in the patient safety movement. (AHRQ, 2012) 83

84 Checklists Used by pilots in pre-flight to find defective equipment, identify potential problems and improve safety Recent studies have found that checklists improve patient outcomes when done before surgery (AHRQ, 2012) 84

85 Checklists The field of cognitive psychology classifies most tasks as involving either schematic behavior, tasks performed reflexively or "on autopilot," or attentional behavior, which requires active planning and problem-solving. (AHRQ, 2012) 85

86 Checklists Failures of schematic behavior are called slips and occur due to lapses in concentration, distractions, or fatigue, whereas failures of attentional behavior are termed mistakes and often are caused by lack of experience or insufficient training. (AHRQ, 2012) 86

87 Checklists In health care, as in other industries, most errors are caused by slips rather than mistakes, and checklists represent a simple, elegant method to reduce the risk of slips. (AHRQ, 2012) 87

88 Checklists By standardizing the list of steps to be followed, and formalizing the expectation that every step will be followed for every patient, checklists have the potential to greatly reduce errors due to slips. (AHRQ, 2012) 88

89 Checklist Controversies Checklists are a remarkably useful tool in improving safety, but care must be taken not to overemphasize their importance: they cannot solve every patient safety problem, and even when checklists are appropriate, certain co-interventions may be necessary to maximize their impact. (AHRQ, 2012) 89

90 Checklists Controversies However, only certain types of errors can be prevented by checklists: errors in clinical tasks that involve primarily attentional behavior (such as diagnostic errors) require solutions focused on training, supervision, and decision support rather than standardizing behavior. (AHRQ, 2012) 90

91 Human Factors Engineering Human factors engineering is the discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments. (AHRQ, 2012) 91

92 Teamwork Training Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. The need for improved teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings. 92

93 Safety Culture High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work. Such organizations establish a culture of safety by maintaining a commitment to safety at all levels, from frontline providers to managers and executives. (AHRQ, 2012) 93

94 Conclusion Medical errors are preventable. Medical errors should be conceptualized systemically. Root cause analysis can be used to develop recommendations Follow professional practice guidelines to reduce error 94

95 Conclusion Professional practice guidelines require that you: Act within your scope and expertise Keep current with continuing education Follow your Code of Ethics Seek supervision/consultation when appropriate 95

96 References Agency for Healthcare Research and Quality. (2012). Patient Safety Primers. Retrieved from: on 08/20/2012. Agency for Healthcare Research and Quality. (2012). Patient Safety Primers: Checklists. Retrieved from: on 08/23/2012. Agency for Healthcare Research and Quality. (January, 2007). Care of adults with mental health and substance abuse disorders in U.S. Community Hospitals. AHRQ Publication No Agency for Healthcare Research and Quality. (March, 2005). 30 safe practices for better health care. AHRQ Publication No. 05-P007 Corey, G; Corey, M.S. & Callanan, P. (2007). Issues and ethics in the helping professions. Belmont: Thomson: Brooks/Cole. Gosbee, J. (2012). (2012). Human Factors Engineering Can Teach You How to be Surprised Again. Agency for Healthcare Research and Quality. Retrieved from: on 08/20/

97 References National Academy of Sciences (n.d.) Free executive summary: To err is human: Building safer health system. Retrieved October 2005 from Rivas-Vasquez, R. A., Blais, M.A., Rey, G.J. & Rivas-Vazquez, A.A. (2001). A brief reminder about documenting the psychological consultation. Professional Psychology: Research and Practice, 32(2), Rooney, J.H. & Vanden Hevel, L.N. (July, 2004). Root cause analysis for beginners. Quality Progress. pp University of South Florida: Louis de la Parte Florida Mental Health Institute. (Oct, 2005). Policy Brief. Suicide risk in the Florida Medicaid population. Tarasoff v. Board of Regents of the University of California, 17 Cal. 3d 425, 551 (1976). 97

98 Florida Statues and Rules Florida Statutes (F.S.): 39 Proceedings Related to Children Psychotherapist-Patient Privledge 394 The Florida Mental Health Act or Baker Act 415 Adult Protective Services Act 490 Psychological Services 491 Clinical, Counseling and Psychotherapy Services Florida Administrative Code (FAC) : 64B4 Board of Clinical Social Work, Mental Health Counseling and Marriage and Family Therapy 64B19 Board of Psychology Current Florida Statues and Administrative Code can be found at Statutes&Submenu=1&Tab=statutes 98

99 Florida Statues and Rules Current Florida Statues and Administrative Code can be found by clicking the link below: Florida Statues If you are having problems with the link - copy and paste this address into a web browser: Statutes&Submenu=1&Tab=statutes 99