Course overview This course focuses on five major components of the problem of medical error for behavioral health professionals. The first section describes the severity of the problem of medical error in the U.S. and outlines the evolution of the patient safety movement. The second section introduces concepts from human factors research that are essential to understanding the complexity of patient safety, and also outlines the importance of a culture of safety. The third section presents three basic strategies to reduce harm: Safety briefings, root cause analysis, and full disclosure. A fourth
section addresses three error-prone situations that are common in behavioral health settings: Inadequate assessment of suicide risk, failure to comply with mandatory reporting laws, and failure to detect medical conditions that have psychological symptoms. The final section describes the psychosocial needs of survivors of medical error and their families. This course is intended for social workers, mental health counselors, marriage and family therapists, psychologists, and advanced practice and psychiatric nurses.
INTRODUCTION
In 1999, the Institute of Medicine (now the National Academy of Medicine) published a seminal report that documented the severity of preventable death and injury in the U.S. healthcare system. In the report, preventable medical death was identified as the eighth leading cause of death in the U.S. In response, patient safety research and initiatives burgeoned in medical settings, particularly hospitals. Unfortunately, the consequences of adverse events are just as serious in behavioral health settings, where safety efforts lag far behind (Oster & Braaten, 2021). The Joint Commission, the accrediting body for more than 22,000 medical and behavioral health settings, defines a sentinel event as any unanticipated event that results in death or serious physical or psychological injury, and that is unrelated to the patient’s illness (Patra & De Jesus, 2022). As part of its mission to help clinicians and organizations provide safe, reliable, high- quality healthcare, The Joint Commission began tracking trends in reported sentinel events in2004. A report summarizing these events from 2010 through June 2022 shows nearly 6% (i.e., 885) of the 13,471 reported sentinel events occurred in behavioral health settings (e.g., psychiatric hospitals, psychiatric units of hospitals, or other outpatient behavioral health facilities) (The Joint Commission, 2022). These figures likely underestimate the number of behavioral health clients who have been victims of sentinel events. One reason for the low estimate is that early data collection was limited to hospitals and did not capture behavioral health patients who were harmed while receiving services in ambulatory care, emergency departments, home care, and long-term care facilities. Another reason is underreporting. The Joint Commission’s sentinel event reporting program is voluntary. Researchers and practitioners have over the past several decades have made strides in studying patient safety and quality; however, the vast majority of research has focused on physical health. Critics have argued that less research of patient safety in behavioral health settings harms not only patients, but the larger professional effort of ensuring patient safety. Researchers also argue that both domains of practice, physical health and behavioral health, will be needed to accomplish important goals for creating safer environments for patients (Thibaut et al., 2019). More broadly, common adverse events in psychiatric inpatient behavioral health units include suicide, elopement, assaults, events involving hazardous items on the unit, falls, overdose, and unexpected death (Mills et el., 2018). It is useful to understand that patients hospitalized for behavioral care face potential risk and harm just as patients hospitalized for general or specialized medical care do. Behavioral health professionals (like professionals in medical settings) may be reluctant to report harm because they fear the consequences of reporting. Because the quality and safety of patient care has not received the same attention in behavioral health as in medical settings, some behavioral health professionals may not be aware of The Joint Commission’s reporting program for sentinel events. Furthermore, behavioral health professionals may be reluctant to report adverse events to appropriate patient safety managers. Unfortunately, behavioral health professionals face a knowledge gap when it comes to patient safety. Behavioral health organizations face a variety of specific patient safety issues, such
as restraint and seclusion, transferring care from one setting to another, preventing infection; reconciling medications, trying to prevent inpatient falls, delays in treatment, and miscommunication. Moreover, safety initiatives are within their infancy stage within behavioral health settings (Brickell & McLean, 2011). While behavioral and medical settings share many of the same safety problems, certain sentinel events are more likely to occur in behavioral health organizations. Suicide, both for patients admitted to an inpatient facility and patients recently discharged (i.e., within 72 hours) , is the most serious and common sentinel event for behavioral health clients (). Because of this, reducing the risk of suicide remains one of The Joint Commission’s Behavioral Health Care and Human Services National Patient Safety Goals for 2023 (The Joint Commission, 2023). There is a clear need for education about client safety that is relevant to behavioral health settings and tailored to the practice needs of mental health professionals. The vast majority of behavioral health professionals receive no instruction on patient safety, through either formal educational programs or in-service training, and this knowledge gap compromises the ability of mental health professionals to protect their clients from harm. It also prevents them from being active participants in the creation of a culture of safety. Let’s examine the bigger picture for this issue. The U.S. healthcare system is facing stressors and challenges as never before. Today, the U.S. population is older and has increased comorbidities. In addition, there are systemic efforts to increase patient access to care, including innovations to care offerings. Once one understands these factors, it is possible to begin to recognize the complexities our healthcare system faces. Providers and frontline staff are overworked and occasionally lacking in essential training, and these limitations collide with financial realities within the healthcare system that creates additional systemic stress. These realities and changes are not without their costs, namely tension within individual systems of care that unfortunately can pose greater risk to patients. Researchers and providers alike argue that our standards of care are not being met and that important work lies ahead for the realization of these standards (Amalberti & Vincent, 2020). This basic-level course focuses on five major components of the problem of medical error for behavioral health professionals. The first section describes the severity of the problem of medical error in the U.S. and outlines the evolution of the patient safety movement. The second section introduces concepts from human factors research that are essential to understanding the complexity of patient safety, and also outlines the importance of a culture of safety. The third section presents three basic strategies to reduce harm: Safety briefings, root cause analysis, and full disclosure. A fourth section addresses three error- prone situations that are common in behavioral health settings: Inadequate assessment of suicide risk, failure to comply with mandatory reporting laws, and failure to detect medical conditions that have psychological symptoms. The final section describes the psychosocial needs of survivors of medical error and their families. This course is intended for social workers, mental health counselors, marriage and family therapists, psychologists, and advanced practice and psychiatric nurses.
EliteLearning.com/Psychology
Book Code: PYFL4024
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