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KEEPING CLIENTS SAFE: ERROR AND SAFETY IN BEHAVIORAL HEALTH SETTINGS 1 [3 CE hours] 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. THIS COURSE FULFILLS THE REQUIREMENT FOR MEDICAL ERRORS 27 [3 CE hours] Psychologists often work with vulnerable individuals in sensitive situations. An important aspect of being a mental health professional, whether you conduct research or provide therapeutic services, is being aware of the ethical issues faced by all psychologists. If you provide psychological services, you are obligated to remain informed about current laws and regulations in your jurisdiction as well as to remain aware of ethical standards and issues. THIS COURSE FULFILLS THE REQUIREMENT FOR LAWS AND ETHICS LAWS, REGULATIONS, AND ETHICS FOR FLORIDA PSYCHOLOGISTS, 2ND EDITION UNDERSTANDING DOMESTIC VIOLENCE 50 [2 CE hours] In this course the learner will gain important information regarding adequately screening for domestic violence/ intimate partner violence, understanding the makeup of an abuser, marginalized/vulnerable populations and IPV, national statistics and identifying and working with victims of IPV in the healthcare setting. It is hoped that after completing this course you will have expanded tools and a trauma informed care lens when working with individuals and further recognize warning signs, appropriately assess and coordinate supportive resources for the victim(s) involved. The learner will gain insight and understanding using a trauma-informed, culturally sensitive, and LGBTQ+ affirming lens when assessing, working with, and supporting survivors/victims of abuse. THIS COURSE FULFILLS THE REQUIREMENT FOR DOMESTIC VIOLENCE 81 [15 CE hours] Anxiety disorders are characterized by states of chronic, excessive dread or fear of everyday situations. The fear and avoidance can be life-impairing and disabling. Anxiety disorders result from the interaction of biopsychosocial factors, whereby genetic vulnerability interacts with situations, stress, or trauma to produce clinically significant syndromes. The influence from hereditary factors and adverse psychosocial experiences on anxiety disorder pathogenesis and pathophysiology is complex, but neuroscience advances have greatly improved the understanding of the underlying factors in the development and maintenance of anxiety disorders. ANXIETY DISORDERS
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PSYCHOLOGY CONTINUING EDUCATION
COGNITIVE-BEHAVIORAL THERAPY: THEORY, TECHNIQUES, AND APPLICATIONS, 3RD EDITION 135 [3 CE hours] This course is an introduction to the cognitive model of psychology and provides the background necessary for understanding the application of techniques associated with first, second, and third-wave cognitive-behavioral therapies. This basic- level course discusses critical components of cognitive therapy, including assessment, case formulation, intervention techniques, and applications, and addresses potential challenges associated with using cognitive therapy and its methods. This course is written for social workers, mental health counselors, marriage and family therapists, and psychologists, providing a foundational understanding of cognitive theory and techniques that can be used either within manualized Cognitive Therapies or to bolster therapeutic skills within other treatment frameworks. DEPRESSION AND SUICIDE 167 [15 CE hours] Depression is a common, debilitating mood disorder. Depression is highly prevalent in medically ill populations, and many persons with depression are either unaware they need professional help or are reluctant to seek it. Although contact with the primary care setting represents a potential opportunity for timely identification and intervention, abundant evidence indicates that many patients with depression are inadequately diagnosed by nonpsychiatrist physicians, with one study showing inadequate assessment and diagnosis even after training. In addition to depression being underdiagnosed in the primary care setting, even when a valid diagnosis is made, treatment is often inconsistent with current practice guidelines. Provider competence and confidence related to the diagnosis and treatment of depression is one factor; other factors that influence patient outcomes have been identified. One of these factors is treatment adherence, and studies have shown that treatment adherence can be positively influenced by the degree of treatment preference for the prescribed treatment modality and by the process of shared decision- making between physician and patient. These widespread shortcomings in the proper diagnosis, treatment, and implementation of treatment adherence strategies among primary care physicians and other primary care professionals represent an ideal educational target.
©2025: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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PSYCHOLOGY CONTINUING EDUCATION
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Keeping Clients Safe: Error and Safety in Behavioral Health Settings
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Laws, Regulations, and Ethics for Florida Psychologists, 2nd Edition
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Understanding Domestic Violence
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Anxiety Disorders
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How do I complete this course and receive my certificate of completion? See the following page for step-by-step instructions on how to complete and receive your certificate. Are you a Florida board-approved provider? Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. Are my hours reported to the Florida board? Yes, your course completion is electronically submitted to the Department of Health’s Board of Psychology within one business day through CEBroker. Is my information secure? Yes! We use SSL encryption, and we never share your information with third parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Psychology you will see our robust FAQ section that answers many of your questions. Simply click FAQs at the top of the page, email us at office@elitelearning.com, or call us toll-free at 888-857-6920, Monday - Friday 9:00 am - 6:00 pm and Saturday 10:00 am - 4:00 pm EST.
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PSYCHOLOGY CONTINUING EDUCATION
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Keeping Clients Safe: Error and Safety in Behavioral Health Settings
3
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PYFL03KC
Laws, Regulations, and Ethics for Florida Psychologists, 2nd Edition
3
$24.00
PYFL03LE
Understanding Domestic Violence
2
$15.00
PYFL02DV
Anxiety Disorders
15 $120.00
PYFL15AD
Cognitive-Behavioral Therapy: Theory, Techniques, and Applications, 3rd Edition
3
$24.00
PYFL03CB
Depression and Suicide
15 $120.00
PYFL15DS
Best Value - Save $78.00 - All 41 Hours
41 $249.00
PYFL4126
iv
PSYCHOLOGY CONTINUING EDUCATION
__________________________________ Keeping Clients Safe: Error and Safety in Behavioral Health Settings
PYFL03KC — 3 CE CREDITS
R elease D ate : 07/10/23
E xpiration D ate : 07/10/2027
Keeping Clients Safe: Error and Safety in Behavioral Health Settings
Faculty Matthew Lucas, MS, LMFT i s a licensed marriage and family therapist practicing within an integrated primary care practice since 2015. He received a Masters of Science in counseling with an emphasis on marriage, family and child therapy from the University of Phoenix, Sacramento Gateway campus in Northern California. Additionally, he has maintained a private practice since 2011, and has previously directed several psychotherapeutic programs. Most notably, he developed and directed a brief therapy, partial hospitalization program for high-risk, self-harming adolescents. Mr. Lucas has completed on-going training in Jungian psychotherapy, and continues to study analytical concepts for treatment purposes. He is also an adjunct associate professor with the University of Maryland Global Campus, teaching in the University’s First Term Experience department. Faculty Disclosure Contributing faculty, Matthew Lucas, MS, LMFT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planner Margaret Donohue, PhD Senior Director of Development and Academic Affairs Sarah Campbell Division Planner/Director Disclosure The division planner and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Audience This course is designed for all licensed behavioral and mental health professionals, including psychologists, social workers, counselors, and therapists. Course Objective 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. Learning Objectives Upon completion of this course, you should be able to: 1. Describe the evolution of the patient safety movement. 2. Explain the human factors approach to client safety. 3. Identify strategies to improve client safety, such as safety briefings, root cause analysis, and disclosure. 4. Identify adverse events that are common in behavioral health settings. 5. Describe the psychosocial needs of victims of medical error and their families.
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Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American
Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. Designations of Credit NetCE designates this continuing education activity for 3 CE credits. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
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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 knowl- edge 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 medica- tions, 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 prac- tice 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 innova- tions 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 medi- cal 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
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 ambula- tory 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 profession- als (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
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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 con- ditions 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. EVOLUTION OF THE PATIENT SAFETY MOVEMENT Researchers have been tracking death and serious injury to patients in the U.S. healthcare system for more than 50 years. As early as the 1970s, anesthesiologists began applying scien- tific approaches to their work in an attempt to reduce harm to their patients. Despite these efforts, it was not until the 1990s that the patient safety movement was launched. Early in that decade, a study of medical records revealed that almost 4% of hospitals in the state of New York had experienced an adverse event, which is defined as an unintended injury caused by healthcare management rather than the patient’s disease and which may result in a longer hospital stay, temporary or permanent disability, or death (Vincent & Amalberti, 2015). Historically, negligent care has remained a chronic problem with our healthcare system. Before The Joint Commission took action in 1997, several dramatic cases captured our collective attention to reveal systemic inadequacies. These widely publicized incidents involved a seven-year-old Florida boy who died after receiving the wrong anesthesia for minor surgery, a Massachusetts healthcare columnist who died from a chemotherapy overdose, a Florida man who had the wrong leg amputated, and an infant in Texas who died from a drug overdose. Coming one right after the other, these tragedies jolted the healthcare community into action. In 1997, The Joint Commission began to require all healthcare organizations participating in its accreditation program to have a process in place for analyzing sentinel events and created a voluntary reporting program to gather information and increase knowl- edge about sentinel events (The Joint Commission, 2012). THE REPORT: TO ERR IS HUMAN In 1999, the secrecy surrounding medical errors was broken when the Institute of Medicine (IOM; now the National Academy of Medicine) published To Err Is Human: Building a Safer Health System. The report captured worldwide atten- tion, and efforts to address the problem began in earnest. This signature report called for an increase in national awareness, namely research, practice, training, and collaboration to reduce
the incidence of accidental harm to patients (Bates & Singh, 2018; Mueller et al., 2019, Oster & Braaten, 2021). Although the report focused on hospitals, the IOM’s definition of a medical error—the failure of a planned action to be completed as intended or the use of the wrong plan to achieve an aim—is as relevant to behavioral health settings as to medical settings. The report recounted two separate studies that documented as few as 44,000 and as many as 98,000 deaths annually from preventable medical accidents. More recent studies have estimated numbers between 210,000 and 400,000 according to data extracted from inpatient health and medical records (Makary & Daniel, 2016; Panagioti et al., 2019). Even at the low end, these figures placed preventable medical accidents as the eighth leading cause of death in the U.S.—ahead of car crashes (43,000 deaths annually), breast cancer (42,300 deaths annually), and AIDS (16,516 deaths annually). These IOM statistics did not include deaths in ambulatory care settings, behavioral health facilities, or long-term care settings, and they did not account for hospital-acquired infections. When the number of deaths resulting from these causes is added, pre- ventable harm to patients in the U.S. healthcare system jumps to the third leading cause of death (Makary & Daniel, 2016). To achieve safer care, the IOM cautioned that American medi- cine would have to look beyond its traditional knowledge base and learn from other disciplines, such as engineering, as well as other high-risk industries, such as aerospace and aviation (Oster & Braaten, 2021). The report introduced concepts that have the potential to transform healthcare’s approach to patient safety. • Most harm to patients occurs because of flaws in the system, not because of individual performance. • Harm will be reduced only as safer systems of care are designed. • For safer systems of care to be designed, the culture of healthcare must change. Mark Chassin, an author of the 1999 report, suggests that hos- pitals and healthcare systems have made critical efforts in the past two decades to reduce the incidence of unintended harm to patients. However, Chassin (2019) maintains that the “one size fits all” approach to systemic change will not be realistic for widespread adoption. In order to elevate the patient safety movement, particularly over the next two decades, the author went on to suggest three areas of critical focus. • Focus on zero harm • Commit to restructuring organizational culture for uninhibited reporting of safety problems • Incorporate process enhancement approaches that use Six Sigma, change management, and lean principles
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human factors attempts to circumvent habits and cognition that can create risky situations. One approach is a mindset of anticipation. The conscious adaptation of anticipating harm or mistakes is fundamentally different than the organizational pattern of simply reacting to error (Oster & Braaten, 2021). Another key concept derived from human factors is the active development of a new organizational mindset—identifying system failures versus merely identifying human failures. Of course, people are responsible for their actions within a healthcare setting; however, the system, or lack thereof, is also a considerable determining factor in adverse patient events. Gravitating to a systems perspective is essential because healthcare in general, and nursing in particular, are operations that are perpetually exposed to frequent interruptions of all kinds. This can create risk for patients, and a systems approach would seek to ameliorate this facet of the system. For example, according to Oster and Braaten (2021), nurses are interrupted approximately 12 times each working hour, and many of these interruptions occur at critical moments that can affect patient safety, such as during the medication administration. Oster and Braaten outline several concrete examples of how human factor thinking can be implemented. Physical Human Factors • Modify the environment to reduce perception time, decision time, and manipulation time • Design the environment to reduce or mitigate the need for excessive physical exertion • Design workstations for ideal or desired physical movement Cognitive Human Factors • Match technology with the user’s expectations and mental models • Minimize cognitive load on staff • Allow for error detection, recovery, and processing • Provide timely and in-depth feedback to staff Organizational Human Factors • Provide opportunities for staff to learn and develop new skills • Allow staff input and control over work systems • Support staff with access to social support • Involve staff in system design, innovation, and evaluation SLIPS, LAPSES, AND MISTAKES James Reason, a psychologist and leading human factors researcher, has studied how people perform in complex environments and has identified three common errors in the workplace (Reason, 1990): Slips, lapses, and mistakes.
CLIENT SAFETY & HARM REDUCTION The error and safety movement has moved toward new con- cepts, including the idea that incidents of nonserious harm should not be minimized and that these nonserious incidents have the unfortunate potential to become serious incidents that lead to significant patient harm (Young et al., 2020). It assumes that humans are fallible, and errors are to be expected, even in the best organizations. The underlying premise of the systems approach is that the human condition (namely, that human beings are fallible and make mistakes) cannot be changed. However, the environment (i.e., the conditions under which humans work) can be modified by building mechanisms into the system to prevent harm or lessen the effects of human error. HUMAN FACTORS: A NEW LOOK AT ERROR The IOM report drew heavily from the field of human fac- tors. Also called human factors research, or human factors engineering, it is a multidisciplinary field that draws upon diverse disciplines—psychology, engineering, industrial design, statistics, and operations research—to understand the interac- tions among people, technology, and work environments and enhance human performance in the workplace. In other words, how do people interact with technology and process systems, but most importantly, how can these interactions be studied, improved upon, and understood to reduce adverse events for patients? From a safety perspective, the field examines work processes, equipment, and devices, and then redesigns them to accommodate the physical and cognitive limitations of human beings. The human factors approach does not excuse individual incompetence or negligence. This approach attri- butes harm to insufficient layers of protection embedded in work processes, emphasizing distraction, communication fail- ures, and fatigue as major contributors to individual mistakes According to Oster and Braaten (2021), the science of human factors considers a variety of factors, such as: • Components of human–system interfaces • Working environments: Organizational, social, and physical • The precise nature of the work being done • Individual characteristics, including performance factors Questions such as how the human factor influences the critical work done in healthcare are central to human factors thinking. For example, how do providers and frontline staff perform multiple tasks simultaneously without sacrificing accuracy and skill? This question is critical, given the automatic mental pat- terns that can govern the actions of staff who all too regularly perform similar tasks over and over again. These professional habits can be quite effective, though they may need to be analyzed if they create conditions for error. The science of
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Slips are errors that tend to occur during automatic, skill-based activities (Reason, 2005). Some examples are inadvertently squeezing ointment instead of toothpaste onto a toothbrush because the two tubes look alike, taking the wrong exit off the highway, or going to answer the door when the telephone rings. Distraction—whether an external stimulus in the environment (such as noise or interruption) or an internal stimulus (such as nagging worry, focused concentration on an upcoming task or event, or a physiological state such as fatigue)—creates the per- fect environmental conditions for a slip (Reason, 2005). A lapse is related to cognition rather than an activity and is therefore not visible (Reason, 2005). Memory failure is an example of a lapse. Lapses tend to occur during rule-based activities such as following a diagnostic guideline or a treatment protocol, and most lapses are not conscious; a step is simply forgotten. But sometimes, under certain conditions, a worker will commit a lapse knowingly. This is most likely to happen when a guideline or protocol seems too difficult, its rationale is not understood, or time constraints make it tempting to skip a step to get the job done (Reason, 2005). A mistake is more complex than a slip or a lapse. It is a deficit or failure in judgment that occurs when specialized knowledge is required, such as when selecting a treatment goal or formulating a treatment plan (Reason, 2005). Mistakes are most likely to occur when a process is complex or when a situation is new or unfamiliar. Some mistakes, such as diagnostic judgments, may go unnoticed for a long time, and when detected, they sometimes remain a matter of debate. For example, the selection of a particular treatment plan or the decision to discharge a client from an inpatient setting is open to a range of opinions. Addressing Slips, Lapses, and Mistakes: Forcing and Constraining Concepts Human factors experts have devised strategies to compensate for slips, lapses, and mistakes. According to Reason (1990), among the basic strategies used in healthcare are redundancy functions, forcing functions, and constraining functions. Of these strategies, redundancy functions are the easiest to apply to behavioral health. A redundancy function is a checking func- tion that builds backups or double-checks into a work process. A supervisor’s countersignature after reviewing and approv- ing the clinical decisions of a student or new employee is one example of a simple redundancy function. A forcing function creates a condition that makes it impossible to commit an error. Early in the patient safety movement, a com- mon slip—overworked nurses mistaking deadly concentrated potassium chloride with its look-alike benign saline solution— was rectified by removing potassium chloride from the nursing units in hospitals. If they needed potassium chloride, nurses had to order it from the pharmacy (Reason, 1990).
A constraining function interrupts an automatic action. It creates a condition in which a worker, who is assumed to be busy and distracted, needs to pause and perform an extra step before tak- ing a deliberate action. A constraining function interrupts the work process and causes the worker to think. Using the above example, if bags of potassium chloride were placed in a loca- tion that was not readily accessible (such as a centrally located pharmacy), the need for a nurse to leave the unit to retrieve the potassium chloride would be a constraining function. An example of a forcing function in behavioral health is a standardized suicide assessment embedded in a computer algo- rithm, with completion required before a patient is cleared for discharge. Reason (1990) outlines an example of a constraining function that uses the same computer algorithm to assess the patient’s status while not making it a condition of discharge. Another example of a constraining function is a team meeting in which all professionals involved in a client’s care provide input into readiness for discharge. Understanding human error—its frequency, type, and preven- tion—was important early in the patient safety movement, in part because of medicine’s longstanding and widespread tradition of focusing on people as the perpetrators of unsafe acts. Early on, such discussion was useful in that it helped professionals begin to grasp the pervasiveness of human error in the workplace. This knowledge was a beginning step toward accepting the inevitability of human error and moving away from blame. However, this narrow understanding, important as it is, fails to improve patient safety on its own because it is when human error occurs in a poorly designed system that tragedy results. To achieve safer care, the focus must be broad- ened beyond the individual worker to include an examination of flaws in the system of work. Safer care cannot be achieved simply by preventing error; it can be achieved only by prevent- ing harm (Reason, 1990). PREVENTING HARM In the language of human factors, complex organizations such as those providing medical and behavioral healthcare have insufficient layers of protection and therefore allow the mistakes made by human beings to continue on their way to cause harm. According to Bates and Singh (2018), it is com- monly the cumulative effect of multiple small mistakes—each unlikely to create an accident alone, but potentially deadly when combined—that can result in a catastrophe. It follows that harm to patients can be prevented only when environmental conditions, especially broken work processes, are identified and redesigned to produce a safer system of care. Healthcare leader- ship will need to pave the way for durable change, changing cultural attitudes within systems of care. Leadership can inspire change to move toward preventing harm (Bates & Singh, 2018).
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__________________________________ Keeping Clients Safe: Error and Safety in Behavioral Health Settings
The Swiss Cheese Model The Swiss Cheese Model (Jedick, 2022) provides a visual depic- tion of the ways that multiple weaknesses, both individual and organizational, can align to cause an accident. The model also shows the different points at which failures occur within an organizational system. Figure 1 illustrates the model and will be used to discuss the concepts necessary for understanding the human factors approach.
the cumulative effects of these organizational weaknesses that come together and produce catastrophe at the delivery level of the organization. Sharp End and Blunt End In the language of human factors, the delivery level of the orga- nization is referred to as the sharp end. It is the point at which active failures occur, and it is called the sharp end because it is the point where system vulnerabilities come together to produce a mishap. It is also that point in the organization where the clinician and client come together. In contrast, the blunt end describes latent (hidden) weak- nesses. Latent factors range from external forces, such as state and federal legislation, to policy and management decisions within an organization. Legislation related to guns, lack of parity in reimbursement for mental illness relative to medical illness, and deinstitutionalization of people with mental illness without adequate funding to support them in the community are examples of external blunt end factors. An example of a blunt end weakness at the organizational level is the failure to develop policies around working overtime—a failure that can contribute to worker fatigue and compromise patient safety. Another example at the organizational level is the decision by management to cut staff positions without redesigning work processes so that remaining staff are not overburdened. Blunt end weaknesses emerge, sooner or later, at the sharp end. A faulty decision made at the blunt end can lay the groundwork for a disastrous encounter at the sharp end (Smith & Plunkett, 2019). Seshia and colleagues (2018) sought to expand the Swiss Cheese Model and found factors contributing to human and systems error, namely unhealthy cultures, poor communica- tion between one or more levels of care, inadequate resources such as staffing and equipment, and the of difficulty accessing resources. Their report went on to identify other negative factors: Failure to promote and practice person- and family- centered care, insufficient shared decision making, unpredict- able situations, time and concentration factors, and failure to seek an independent reliable opinion (outside view) when the situation is critical. On the individual level, Seshia and colleagues (2018) found both provider and patient cognitive- affective states can catalyze error. Importantly, they note that cognitive-affective states influence human error, yet generally remain overlooked in patient safety research. These provider states can include: • Biases in judgment and decision making (these can relate to the professional’s biases related to a patient’s social status, history, medical status [e.g., obesity], age, gender, and so on) • Sleep deprivation/fatigue • Psychological state, including dysphoria, personal life stressors, and burnout
THE SWISS CHEESE MODEL
Modified from Jedick, R. (2022). Human factors in medicine: A medical error model that isn't full of holes. Emergency Medicine News, 44(11), 24. Figure 1
Active and Latent Failure The Swiss Cheese Model describes two types of failures: Active and latent. An active failure is defined as an operational error at the delivery level of the organization, such as a clinician’s diagnostic error. An active failure may result from action (such as a misdiagnosis), inaction (such as failure to report abuse), or faulty decision making (following an order without questioning its appropriateness). In contrast, a latent failure is defined as an environmental factor. An environmental factor can lie dormant in an orga- nization for days, weeks, or months, until it finally lines up with other system weaknesses and contributes to a disaster. One example of a latent failure is reduced state and federal funding for mental health services. Decreased funding produces budgetary constraints within an organization. Budgetary constraints lead to inadequate resource allocation. Inadequate resource allocation, in turn, creates a number of vulnerabilities at the delivery level of the organization, such as understaffing, unwieldy caseloads, less time spent with clients to understand their issues, reduced in-service training, and inadequate supervision for inexperienced clinicians. It is
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Keeping Clients Safe: Error and Safety in Behavioral Health Settings _ ________________________________
CULTURE OF SAFETY AND HIGH RELIABILITY ORGANIZATIONS The concept of a safety culture originated outside of health- care and emerged from studies of high-risk industries such as nuclear power, aerospace, and aviation. Researchers identified a culture of safety embedded within what they called a high reliability organization (HRO), which is best described as a complex organization that engages in high-risk activities but experiences few catastrophes (Oster & Braaten, 2021). Despite its hazardous environment, an HRO operates for long periods of time without catastrophe because of its “error-tolerant” cul- ture, which means that it recognizes the futility of eliminating human error and designs work processes in which errors can occur without leading to disaster. Below are some of the charac- teristics of HROs as they might relate to behavioral healthcare. HROs create a culture of safety by first acknowledging the risky nature of their activities and then operate to effectively manage risky situations through organizational control and the ongoing calculation of probabilities of error. Clearly, this approach is typified by facing risks, understanding them, and trying to anticipate their probable occurrence. Moreover, the HRO will seek to identify weaknesses within their system and create management and process steps to miti- gate these risks. A culture of safety encourages—and actively fosters within an HRO—collaboration across ranks, disciplines, specialties, and departments to solve safety problems. The HRO focus is on teamwork to proactively identify latent (hid- den) vulnerabilities (Oster & Braaten, 2021). A culture of safety is committed to learning. In a culture of safety, adverse events and near misses (close calls) are viewed as opportunities to improve the system. For this type of learn- ing to occur, the organization must develop an atmosphere of trust that encourages workers to report adverse events and near misses. In this transparent, supportive reporting culture, workers are confident that they can report problems without being punished. When something bad happens, the focus is on what happened rather than who did it. Oster and Braaten (2021) define HRO principles as follows: • Sensitivity to operations: Systems and processes that affect client care are constantly assessed to prevent risks. • Reluctance to simplify: Simplistic explanations of failure (e.g., unqualified staff, inadequate training, communication failure) are avoided, and underlying factors that place clients at risk are explored. • Preoccupation with failure: Near misses are viewed as “symptoms,” that is, evidence that an area or work process needs to be improved to reduce potential harm to clients.
• Cognitive overload that impairs the individual professional Patient-related factors that impact human error include: • Communication challenges (e.g., language barrier and cognitive dysfunction) • Adherence (compliance and concordance with medical advice) • Cognitive-affective biases of patients that influence personal healthcare decisions (same as biases listed above) UNDERSTANDING ORGANIZATIONAL CULTURE The difficulty of culture is that it an abstraction, culled and cre- ated—at minimum-- from the milieu of subjective attitudes and behaviors of people, both individuals and groups. Moreover, there are varying definitions of what culture exactly is. It is real, but it is veiled, somewhat invisible. The visible effects are seen within the patterns of thought and behavior that the group demonstrates most often. Because of these characteristics, culture can often be unquestioningly accepted, followed, and continued by people. This can be a problem within groups. Organizational culture is no different from our larger human and societal culture (Oster & Braaten, 2021). Oster and Braaten (2021) point out that researchers who study organizational culture use several defining characteristics to help identify the elusive nature of organizational culture. • It does really exist. • It is characterized by ambiguity. • It can be malleable and specific. • It is the result of group interactions and is thus a social construction. • It exists in healthcare. Furthermore, there are drivers and factors that ultimately cre- ate or contribute to the creation of a specific organizational culture. One of these factors is identified as an artifact, namely processes and structures that have survived and existed within the organization for a considerable amount of time. These artifacts can be the direct result of espoused positions or goals of the organization that have also had a considerable life span, adopted and repeated by successive groups of lead- ership, providers, and frontline staff. Additionally, much of organizational culture can often be further linked to conscious and unconscious assumptions held within the organization by current staff or previous staff. Certainly, organizational culture is palpable, sometimes powerful, but this milieu of historical and assumptive factors can make it more difficult to objectify, study, and change (Oster & Braaten, 2021).
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