CONCLUSION
The 1999 IOM report broke through the secrecy surrounding medical errors and fostered the growth of the patient safety movement, creating the research and clinical landscape that exist today. Patient safety has been the focus of many well-intentioned initiatives for more than a decade, but healthcare safety is still a work in progress and needs continual improvement. Few in the scientific and clinical community would dispute this claim. While many admirable projects have been studied and implemented, the overall field of patient safety suffers, as do many clinical fields, from fragmented definitions, insufficient regulatory oversight, and the clinical inertia that allow current practice to simply keep operating. The culture of medicine pervades most behavioral health settings. This cultural attitude can blame clinicians for adverse events rather than focusing on systems. To be safe, healthcare must learn from HROs, which perform high-risk activities with few accidents and adopt the human factors approach that acknowledges human fallibility, focusing on designing work processes that prevent harm and improve patient safety. Strategies to improve patient safety include safety briefings, root cause analysis, and full disclosure to patients and families about the circumstances surrounding adverse events.
Preventable mistakes are just beginning to get the attention they deserve in behavioral health settings. Adverse events that are common in behavioral health settings include suicide, unreported abuse and neglect, and medical illnesses that are misdiagnosed as psychiatric conditions. The Joint Commission has placed these as top priorities for client safety in behavioral health. Licensed behavioral health professionals are advised to check with their licensing boards as to specific continuing education requirements on medical error prevention. Behavioral health professionals can play an important role in creating a safety culture by providing mental health services for victims of medical error. Victims experience symptoms similar to those experienced by other trauma survivors, such as burdens of betrayal, loss of trust, isolation, and heightened vulnerability. Professionals involved in adverse events that harm their clients are called second victims, and they may suffer from guilt, sleep disturbance, depression, anxiety, and decreased self-esteem. Behavioral health professionals can provide safer care by learning to identify vulnerable clients and error-prone conditions in the work setting and by providing psychosocial services to victims of medical mistakes.
WORKS CITED https://uqr.to/KCSafe
KEEPING CLIENTS SAFE: ERROR AND SAFETY IN BEHAVIORAL HEALTH SETTINGS Self-Assessment Answers and Rationales 1. The correct answer is B.
3. The correct answer is B. Rationale: From a speaking-up perspective, Janet’s best course of action is to speak up to Mark. If this is a pattern of oversight, or becomes a pattern of oversight, an adverse patient event is likely to occur. Janet is naturally anxious about speaking up to her supervisor because she is a new employee on the unit; however, she has a duty to the patients and the hospital to be responsible and work to keep all patients safe. 4. The correct answer is C. Rationale: This revelation of suicidal ideation and planning is critical. Ellen can act now to obtain authorization to speak with his wife and primary care provider, including them in creating a safer system of care for her new patient. Because the patient is new, it would be unwise to prematurely force him toward psychiatric admission—he might refuse, or potentially even more prematurely terminate with Ellen. Building rapport and creating a support team (his wife and primary care provider) establish the right clinical approach to keep her patient in therapy, which is the safest approach at this moment.
Rationale: From an HRO perspective, it would be a mistake to eliminate steps in a critical patient process, especially if the only objective is to save time for frontline staff members. Mistakes can certainly occur when necessary processes are overly simplified and should therefore be critically resisted and examined to determine how they affect the possibility of patient risk. 2. The correct answer is A. Rationale: From an RCA perspective, a critical element for success is the application of an RAC process to the exact context of a particular setting or practice. General RCA concepts might apply; however, specific factors will quickly need to be addressed in order for the new program to be effective. This customization allows for concepts to serve the precise needs of patients, providers, and leadership within a very specific healthcare environment.
Page 65
Book Code: PCUS1525
EliteLearning.com/Counselor
Powered by FlippingBook