Download Preventing Medical Errors in Behavioral Health

Title of Course: Preventing Medical Errors in Behavioral Health
CE Credit: 2 Hours
Learning Level: Intermediate
Authors: Susan Mitchell, PhD; Catherine Christie, PhD & Leo Christie, PhD
Abstract:
This course is intended to increase clinicians’ awareness of the types of errors that can occur within mental health
practice, how such errors damage clients, and numerous ways they can be prevented. Its emphasis is on areas within
mental health practice that carry the potential for "medical" errors. Examples include improper diagnosis, breach of
confidentiality, failure to maintain accurate clinical records, failure to comply with mandatory abuse reporting laws,
inadequate assessment of potential for violence, and the failure to detect medical conditions presenting as psychiatric
disorders (or vice-versa). It includes detailed plans for error reduction and prevention like root cause analysis, habitual
attention to patient safety, and ethical and legal guidelines. The course includes numerous case illustrations to help
demonstrate common and not-so-common behavioral health errors and specific practices that can help clinicians
become proactive in preventing them. There is a new section on preventing medical errors in the use of technology.
*This course satisfies the medical errors requirement for license renewal of Florida mental health professionals.
Learner Objectives:
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Name at least six examples of medical errors in behavioral health practice
Distinguish between human error and system failures
List examples of medical errors that can result from improper use of technology
Identify the conditions under which mental health professionals have a “duty to warn”
Name ways in which the informed consent process can help prevent practice errors
List eight strategies mental health professionals can use to prevent medical errors
About the Authors
Susan Mitchell, PhD, has taught the Preventing Medical Errors course for over six years at the Florida Dietetic
Association annual meeting, is a contributing author to Macmillan Reference USA's Guide to World Nutrition and Health
and serves on the Advisory Board for the Keiser University Dietetics and Nutrition Program.
Catherine Christie, PhD, is a Florida-licensed nutritionist who earned her PhD from Florida State University. She
currently serves as Associate Dean and Nutrition Graduate Program Director at the University of North Florida and has
led 1,000-plus continuing education seminars for healthcare professionals.
Leo Christie, PhD, is a Florida-licensed Marriage and Family Therapist with a doctorate in Marriage and Family Therapy
from Florida State University. He has more than 20 years of experience in private practice with a specialty in child
behavior disorders and as an instructor of over 500 live continuing education seminars for healthcare professionals.
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Preventing Medical Errors in Behavioral Health
Introduction
A 56-year-old white male, Mr. X, began seeing a psychologist in order to receive help with long-standing moderate-tosevere depression, which was adversely affecting not only his personal life, but also his ability to function effectively at
work. He selected a psychologist, Dr. Y, who was on the provider panel of the Managed Care Organization (MCO)
selected by his employer. During the course of therapy, Mr. X used a number of antidepressant medications and once
was briefly hospitalized for an acute depressive episode. After six months of therapy, Mr. X and Dr. Y agreed that – with
the results of the months of therapy and with the help of his medication – he was stabilized and ready to be discharged
from treatment.
Approximately one year later, Mr. X applied for a security clearance for work associated with a job assignment that
included a large government contract that his employer had negotiated. After doing a background check, the agency
performing the security work declined to give Mr. X the needed clearance to work on the contract. While the specifics of
the background check were not formally released to Mr. X, he was told by one of their representatives that an individual
with a history of psychological treatment generally would not qualify for a security clearance at the level for which he
was applying.
In view of Mr. X’s failure to receive the necessary security clearance and his subsequent inability to work on the
government contract, his employer terminated him, leaving him without any income. Following three months of
unsuccessful attempts to secure a new job, Mr. X once again fell victim to severe depression and was hospitalized for a
suicide attempt involving an overdose of prescription medications. In his admission interview with the psychiatrist, he
stated that he did not understand how his prior hospitalization and treatment for depression had come to light in the
context of a background check initiated by his employer. He added that he thought that any discussions he had had with
Dr. Y were confidential and could not be divulged without his explicit permission.
Too late, Mr. X learned that when he began treatment with Dr. Y, he had signed an “informed consent” statement,
which informed him – among other things – that certain aspects of his therapy would be reported to the managed care
organization and that some of it could become part of his permanent medical record at the Medical Information Bureau,
a national data bank. Such information can be examined when one applies for life or health insurance or a security
clearance. Mr. X stated that he was not aware that his personal health information could be shared in such a way and
did not remember Dr. Y discussing it with him.
In addition to errors such as this one, a quick scan of your local paper will likely reveal some shocking medical error
headlines:
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Woman goes to hospital to give birth and becomes quadruple amputee
Surgical instruments mistakenly washed in hydraulic fluid
Hospital patient is given roommate’s heart medication
Surgeon removes patient’s wrong leg
Appendix mistakenly removed instead of gallbladder
Routine hip replacement results in death
This course will take a closer look at medical errors, both in the medical and
behavioral healthcare arenas, and provide a plan for how they can be
avoided. Florida statutes and ethical considerations for mental health
professionals will also be discussed.
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Scope of the Situation
A 2011 Consumer Reports Poll on Hospital Safety (Safe Patient Project, 2011) interviewed 1026 adults ages 18+ using a
nationally representative probability sample. The results:
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77% expressed high or moderate concern re: harm by hospital infection during hospital stay
71% expressed high or moderate concern re: harm by a medication error
65% were similarly concerned about surgical errors
Virtually all of the consumers (96%) said hospitals should be required to report medical errors to state health
departments. Currently most states (including Florida) do not disclose facility-specific information to the public about
mistakes. Yet 82% want each hospital’s medical error record to be available to the public. According to a study in Health
Affairs (Classsen et al., 2011), hospital errors are more common than suspected…ten times more common. Medical
errors and other adverse events occur in one-third of hospital admissions according to the authors. The more you look
for errors, the more you will find.
Medical errors continue to be a major issue in today’s health care arena. Yet it’s been over a decade since the eye
opening report from the National Academies’ Institute of Medicine Report To Err is Human: Building a Safer Health
System (1999): revealed these statistics:
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Approximately 50-100,000 Americans die each year from medical errors
Preventable medical errors cause an additional one million injuries to Americans
Medical errors cause more deaths than breast cancer, AIDS or even car accidents
7,000 people die from medication errors alone
Repeat tests, disability, and death due to error cost the US $17-38 billion each
year
Less dramatically publicized – but often equally damaging to clients – are those mistakes
that can occur in the practice of behavioral health. Such errors generally fall into the
categories of:
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Improper diagnosis
Breach of confidentiality
Failure to maintain accurate clinical records
Failure to comply with mandatory abuse reporting laws
Inadequate assessment of potential for violence
Failure to detect medical conditions presenting as psychiatric disorders (or vice-versa)
Such errors of omission or commission can result in lasting damage to clients just like those that occur in the medical
arena. Diagnostic errors lead directly to one of two outcomes: either applying improper – and therefore ineffective and
unneeded – treatment, and/or the failure to apply effective treatment. Breaches of privacy and confidentiality can
precipitate a cascade of adverse events for clients, often reaching far into not only their personal lives, but even into
relationship and occupational spheres.
Mental health professionals are required by several levels of ethical and legal standards to maintain accurate clinical
records in order to assure continuity in the course of a client’s treatment. The failure to do so can cause harm resulting
from the loss of a clear and coherent course of therapy. Failure to comply with mandatory abuse reporting laws and
inadequate assessment of potential for violence lead to obvious dangers to clients and others. Finally, confusing medical
conditions with psychiatric ones can lead to damaging – even tragic –consequences for clients due to the failure to offer
or refer for appropriate treatment.
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A Closer Look at Medical Errors
How is “Medical Error” Defined?
Merriam-Webster’s Collegiate Dictionary defines error as: “An act involving an unintentional deviation from truth or
accuracy." The Institute of Medicine (IOM) defines a medical error as: "The failure to complete a planned action as
intended or the use of a wrong plan to achieve an aim." A medical error occurs in either the planning stage or the
execution stage. For example, an individual with Borderline Personality Disorder is misdiagnosed as Bipolar Disorder and
receives a medication for the wrong disorder. Is this an error in planning or in execution?
What about an Adverse Event?
An adverse event is defined as "an injury caused by medical management rather than by the underlying disease or
condition of the patient." Adverse events resulting from medical errors are considered preventable adverse events. A
client who is being treated by a professional counselor for depression discusses her suicidal thoughts in a therapy
session. The counselor fails to undertake immediate steps for dealing with a behavioral emergency, and the client is
hospitalized that night after taking an overdose of a prescription medication.
Medical Errors Were Once Largely Unnoticed, But Not Anymore
The issue of medical errors is not new. Lucian Leape, M.D. and David Bates, M.D. conducted initial landmark research in
the early 1990s. Their findings were supported by the Agency for Health Care Policy and Research, now the Agency for
Healthcare Research and Quality (AHRQ). Because medical errors typically affect only one person at a time, they are
viewed more as isolated events that receive little public attention as compared with a train wreck or a plane crash.
But that mentality is quickly changing. In 2005, Pennsylvania became the first state to publicly report hospital infection
rates and the cost of such infections. Several other states including Florida, Virginia, Missouri, and Illinois have such laws.
However, in the decade since the IOM report was published, little progress has been made implementing reform to
improve patient safety according to Consumers Union, the nonprofit publisher of Consumer Reports, in a 2009 report
“To Err is Human-To Delay is Deadly.” In their report, the Consumers Union reviewed several key IOM recommendations
and found that twenty four states do not have medical error reporting requirements and most states that require error
reporting do not disclose facility-specific information to the public about mistakes. While the reporting of hospital
infections is increasing, twenty four states do not require infection reporting. The Consumers Union recommendation is
for facility-specific reporting of medical harm that is mandatory, validated, and public.
http://www.consumersunion.org/pub/core_health_care/011324.html]
How are Florida Hospitals Doing?
According to the Leapfrog Group (2012), 400 people die daily from medical errors - which is equivalent to a daily jet
crash. The Leapfrog Group, a nonprofit organization, released their updated Hospital Safety Score (11/2012), which
grades A-F based on patient injuries, medical and medication errors and infections. More than 2600 US hospitals were
evaluated. You can check the score of any Florida or other hospital at hospitalsafetyscore.org.
The Hospital Safety Score now identifies “D” and “F” hospitals that represent the most hazardous environments for
patients. The Hospital Safety Score accounts for the data updated over the last six months, most covering hospital
performance in 2011, and uses a modified methodology based on research and public comments. According to the
report, of the 2618 general hospitals issued a Hospital Safety Score, 790 earned an “A,” 678 earned a “B,” 1004 earned a
“C,” 121 earned a “D” and 25 earned an “F.”
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What is the Worst Month for Medical Errors?
The worst month for medical errors, according to a study in the J Gen Intern Med (Phillips and Barker, 2010), coincides
with the yearly influx of new medical students. During this particular month fatal medication errors spike by 10%. Errors
also included incidents of the wrong drug given, drugs taken inadvertently and accidents in the use of drugs in medical
and surgical procedures. The month? July.
Change in Prescription Procedures
In past years, getting a prescription filled at your local pharmacy was also
much more foolproof. You took your written prescription from your
physician to your pharmacist and if he or she could read it, you were
given the medication. Now the following scenario is much more likely:
Your health maintenance organization (HMO) or the prescription benefit
management company (PBM) working with the HMO intercepts the
physician prescription, possibly denies coverage and sends it back to the
physician for change. Then the prescription could go to a central filling
facility where no one knows your name or history. Due to these multiple
steps, the possibility for error has greatly increased.
Illegible prescriptions are also a cause of medical errors. A number of states are passing laws termed ‘safe script’ that
deal with illegible handwriting on prescriptions. Idaho, Montana, Tennessee, Washington, Maryland and Florida all have
passed such laws. For example, Florida passed this statute:
456.42 Written prescriptions for medicinal drugs. A written prescription for a medicinal drug issued by a health care
practitioner licensed by law to prescribe such drug must be legibly printed or typed so as to be capable of being
understood by the pharmacist filling the prescription; must contain the name of the prescribing practitioner, the name
and strength of the drug prescribed, the quantity of the drug prescribed in both textual and numerical formats, and the
directions for use of the drug; must be dated with the month written out in textual letters; and must be signed by the
prescribing practitioner on the day when issued.
A Note on Prescription Medications and Behavioral Health Care Professionals
With the exception of psychologists who have prescribing privileges, behavioral health care professionals do not manage
their clients’ medications. Nevertheless, many of the clients who are receiving treatment from mental health
professionals may also be using psychoactive medications. Medications have effects, side effects, indications and
contraindications. Clients frequently see their therapists more regularly than they see their prescribing physicians.
Therefore, it is important for all clinicians to be familiar with the medications their clients are using so that they can be
alert to symptoms that may be medication side effects. In such cases, clients should be referred back to their prescriber
for consultation.
There needs to be a careful balance between maintaining alertness to drug effects and side effects on the one hand, and
avoiding the error of offering any suggestions on the clients’ medication use, on the other. Making even subtle
recommendations on drug usage or dosing would be a different kind of error: practicing beyond ones’ professional
expertise and qualifications. Avoiding error and protecting the client’s best interests in this case means knowing enough
to identify potential drug reactions and making the direct referral back to the client’s prescribing physician.
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Medical Errors in Schools
In 2000, The Journal of School Health reported on a survey of 1,000 members (649 completing the
survey) from the National Association of School Nurses and found that on any given day about 6% of
children receive medication at school. Approximately 76% of the nurses delegate the administration
of these medications to unlicensed personnel, with secretaries making up 66% of the persons most
likely to dispense. Forty-nine percent of the nurses reported errors in administering the medications
with the most common error being a missed dose. The use of unlicensed personnel and the large
number of students receiving medications were pinpointed as the contributing factors in the errors.
Fast Forward a Decade
In an article in Pharmacy Times, Gaunt (2010) reported that in any given week, 56% of children younger than 18 years of
age take at least one medication, 27% take two or more and 21% use at least one prescription drug. These numbers
make safe and correct medication administration during school hours a challenge. American school systems deliver
medication to more patients than large hospital or nursing home systems.
Approximately 6% of school-aged children receive medications while in school, and 80% of school-related medication
errors reported involved missed doses. Proper medication management improves outcomes for chronic conditions in
children whereas disease progression, complacency, and bad habits are reinforced when medications are not
administered as ordered during school hours. Due to budget cuts, many school systems do not have a dedicated nurse
onsite and leaves school staff, mostly untrained for medication delivery, responsible for medication management.
Several suggestions to decrease medication errors in schools include:
Consider a program, such as FDA’s Medicines in My Home for parents and/or students.
http://www.fda.gov/medsinmyhome
Have a pharmacist help school systems develop policies and implement practices for medication storage and
distribution, the importance of the medications’ usage instructions and the possible side effects to look. Have a local
pharmacy to call for medications questions.
Facilitate the training of students and caregivers on the proper storage, administration, and waste of medications.
Mental health providers also need to communicate accurately with the school regarding instructions for administering
the medications and follow up on any problems or questions. There are a number of things that can go wrong during
this process. First, if school personnel are not properly trained and informed about the medications, dosing, and possible
side effects to look for, they may not be cognizant of the importance of the medications’ usage instructions. If a child
misses a prescribed dose, symptoms are likely to occur and disrupt the child’s ability to pay attention and behave
properly.
Second, if school personnel are not trained to arrange comfortable ways for the child to come to the office to receive
medications, the child may feel embarrassed and reluctant to be identified as one who is taking medications. Third,
there may be some school personnel who have a negative attitude toward the use of psychiatric medications and may
act out their reluctance in a number of ways that are not beneficial to the child.
The role of mental health workers in these scenarios is to maintain an open line of communication with parents,
teachers, school nurses, and guidance counselors for the purpose of preventing errors or omissions in administering
medications to children at school. The physicians who prescribe the medications are less likely to take the time to do so.
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Medical Errors in Behavioral Health
Real Life Stories
The following are actual cases found in the official public records of the Florida Department of Health Division of Medical
Quality Assurance. Licensing board complaints are a matter of public record. Nevertheless, the case reports outlined here
are included only for the purpose of illustrating the kinds of errors that occur in the practice of behavioral health and
therefore contain no specifics like names, dates, or case numbers.
Case #1: A court order required a Florida couple to participate in marital counseling sessions prior to initiating divorce
proceedings. The order did not specifically require the therapist to provide treatment reports to the court.
The couple selected a social worker, who saw them for marital counseling sessions on two occasions. Following the
second session, the wife sent a letter to the social worker stating that she would not be attending any additional
counseling sessions.
The social worker then contacted the husband, requesting that he sign a waiver permitting the social worker to submit a
summary report of the marital counseling to both parties’ attorneys. The husband refused to sign a waiver, advising the
social worker that he did not consent to the release of any information about him to anyone. The social worker sent a
letter to the wife’s attorney that contained personal information about the husband that was learned during the marital
counseling sessions.
Section 491.0147 of the Florida Statutes states that any communication between a licensee and a client shall be
confidential EXCEPT when: the licensee is a defendant in a criminal or disciplinary action arising from a complaint filed
by the client, the client agrees in writing to waive confidentiality, or – in the case of a family – each family member
agrees in writing to waive confidentiality, or when there is a clear and immediate probability of physical harm to the
client or other individuals. None of the circumstances permitting waiver of confidentiality were present in this case.
The Board found that the social worker was in violation of Florida 491 Statutes by failing to maintain in confidence a
communication made by a patient of client in the context of such services.
Case #2: Pursuant to a series of classroom incidents of threatening behavior on the job, a teacher was referred by the
school board to a Florida psychologist for an evaluation of his fitness-for-duty. In their first meeting, the psychologist
presented the teacher with consent forms that outlined HIPAA privacy protections that would apply if he were seeking
psychotherapy but did not apply in a fitness-for-duty evaluation. The consent forms also failed to include required
disclosure about the nature and purpose of the evaluation.
She then administered two neuropsychological assessment measures without explaining why those particular tests were
selected to address the evaluation of fitness-for-duty. She did not reference the specific normative set and which
version of the test she used in citing standard scores for the examinee’s test results. She also failed to include two
primary validity indices within the MMPI-2 that are considered essential in an evaluation of the test results in a fitnessfor-duty evaluation. Furthermore, there were three validity measures that
were included and suggested that the interpretation of the overall profile
of the test might not be reliable. The psychologist did not address these
findings in her report.
In the course of the evaluation process, the psychologist did not include a
number of standard inquiries, such as medical history, a mental status
exam, quality and quantity of speech, as well as a number of other lines of
inquiry that are considered part of such an evaluation.
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Finally, when she submitted her final evaluation report, the teacher strongly objected to her wording of the evaluation’s
Reason for Referral (“incidents of threatening behavior on the job”) and demanded that she revise it. The psychologist
did so, acceding to the wishes and demands of the examinee.
The Board concluded (Count 1: Inappropriate Use of Forms) that the psychologist violated Florida 490 Statutes by failing
to meet minimum standards of performance in providing accurate and appropriate privacy information and consent
forms in the initial session of the evaluation. The client was presented with inaccurate and misleading information about
his right to privacy and the purpose of his psychological examination.
The Board concluded (Count 2: Use and Interpretation of Test Instruments) that the psychologist violated Florida 490
Statutes by failing to assess the statistical validity and interpretive limitations of test results. The test results may not
have been reliable, thus portraying the examinee in a way that could be inaccurate.
The Board found (Count 3: Incomplete Evaluation) that the psychologist violated Florida 490 Statutes by failing to meet
minimum standards of performance when she did not conduct a thorough fitness-for-duty evaluation. Several important
aspects of the examinee’s functioning were not presented in the evaluation’s final report.
The Board found (Count 4: Revision of Reason for Referral) that the psychologist violated Florida 490 Statutes by
significantly revising a statement in her original report in order to please the examinee. An important part of the final
report was thus dictated by the examinee, rather than by the psychologist.
Case #3: A Florida Licensed Mental Health Counselor (LMHC) and another woman (AS) participated in the same weekly
12-step self-help group (SHG) for several years. The two also shared the same Sponsor. The counselor, in her practice at
an agency, held regular group therapy sessions for individuals who may have experienced emotional trauma from
childhood sexual abuse.
Based on personal information disclosed during the SHG meetings, the counselor suggested to AS over a period of
months that AS had probably been sexually abused as a child and that the counselor’s group therapy sessions might
prove beneficial. AS had no memory of or concern about childhood sexual abuse and resisted the suggestions of the
counselor.
Eventually, AS agreed to enter the therapy group and attended two sessions. During this time, both she and the
counselor still attended the weekly SHG meetings, where the counselor was the scheduled speaker. In the meeting, the
counselor disclosed specific details of her own childhood sexual abuse, which AS found deeply disturbing because the
counselor was now not only a co-member of the SHG, but also the counselor in charge of the therapy group AS had just
started to attend.
When AS told the counselor she was upset about the situation, the counselor discussed it with the group therapy
members and decided that AS should not return to the group. AS was shocked by this, stating that she felt hurt,
abandoned and betrayed by the counselor’s conduct.
Subsequently, the counselor discussed confidential details of AS’s group therapy sessions with two unlicensed members
of the SHG, identifying AS by name during those discussions.
In the resulting licensing board complaint, the Board found that the counselor violated Florida 491 Statutes by
maintaining a dual relationship with the client, showing a lack of professional judgment as to the boundaries that must
exist between a psychotherapist and client.
The Board also found that the counselor breached patient confidentiality when she divulged the content of a private
conversation with AS to members of the therapy group and later with two unlicensed members of the SHG.
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Comments on These Cases
In each of these three cases, the clients’ best interests were damaged
by errors on the part of the licensed professionals. How are clients
damaged by breach of confidentiality? In at least three ways: 1)
sensitive, personal information intended only for the ear of the
therapist is leaked to unintended parties; 2) the information that is
leaked frequently causes far-reaching problems for the client; 3) any
breach of any client’s confidentiality by any therapist damages the
credibility of other therapists with other clients. This obviously runs
counter to the establishment of a therapeutic relationship, making it
more difficult for clients to trust that their personal information will
remain private.
Readers who examine the three cases outlined here may find the
actions of the therapists involved to be nearly incomprehensible. What
were they thinking? The point is – and this will be a major emphasis in
this course – they were NOT thinking in ways that are consistent with
the minimum standards of performance that are expected and mandated for licensed professionals. In the end, this is
not difficult. There is no substitute for informed, thoughtful, detailed planning and record keeping. A large number of
suggestions for avoiding medical errors will be presented throughout the remaining pages of this course.
Other Examples
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A social worker receives a subpoena for clinical records on a client she treated three years ago. When she
locates the file for that client, she finds that there are no progress notes for the last five sessions.
A marriage and family therapist who is seeing a couple with a volatile relationship fails to accurately assess the
potential for violence in the husband. The wife is subsequently hospitalized with injuries.
Diagnostic error, such as misdiagnosis leading to an incorrect choice of therapy, or misinterpretation of test
results.
A social worker has one session to assess a child who is referred by the school counselor for disruptive behavior
in the classroom. She suspects that the child is a victim of abuse at home, but delays reporting the suspected
abuse to the Florida Department of Children and Families.
A psychologist treating a 59-year-old woman for symptoms of grief and anxiety receives a call from his client
stating she thinks she is having a heart attack. He assures her that the symptoms are only anxiety and attempts
to calm her. She is hospitalized later that day for a mild heart attack.
Failure to maintain competency through continuing professional education.
A licensed mental health counselor sees a distressed client for the initial interview but does not complete the
informed consent process because the client is agitated. Later in therapy, a payment issue comes up, and the
counselor realizes that the informed consent form was never signed.
A mental health therapist erroneously diagnoses a bipolar client as having Attention Deficit Hyperactivity
Disorder, resulting in ineffective treatment and inappropriate medication.
A social worker fails to accurately assess a client's suicidal potential resulting in a suicide attempt and
subsequent hospitalization.
A psychologist administers a battery of tests to a child, but then fails to provide a referral for treatment
indicated by the test results.
A marriage and family therapist treating a couple for relationship difficulties fails to recognize that the husband
is suffering from severe depression.
A mental health counselor fails to secure clinical record files resulting in a breach of patient confidentiality.
A therapist reveals confidential information about a patient to a family member.
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Medical Errors and the Use of Technology
In an article on social media and health care, Hawn (2009) quips “Take two aspirin and tweet me in the morning.” We
therapists, whether we were trained in this century or the one past, find ourselves practicing in a digital world. Even in
this early part of the 21st century, the list of digital communications applications – cell phones, email, texting, Facebook,
Twitter, Skype, cloud computing, electronic medical records, webcams, etc., etc. – is endless and still growing. As our
careers progress, the proliferation of such technologies is likely to continue to outpace our capacity to stay current. With
the introduction of each innovation, the challenges to reasonably error-free practice will continue to multiply.
As is the case with most innovations, there are benefits and there are risks. The benefits are usually seductive, promising
increased speed, efficiency, and convenience. The risks are usually hidden, requiring thoughtful consideration before
they show themselves. The point here, within the context of preventing medical errors in behavioral health, is that the
use of this technology has become so routine that clinicians might adopt it mindlessly without carefully thinking through
the potential consequences in therapy situations. Sometimes we may even make a conscious decision to trade security
for convenience. The results can include unanticipated breeches of confidentiality or the transmission of private
information to unintended parties, sometimes leading to severe damage to clients.
In an article in the Annals of the American Psychotherapy Association, Michael Freeny (2007) wrote:
“The gravitation to an electronic medical record promises much greater speed and efficiency in using client
medical information in critical situations. However, it is a direction that also contains great confidentiality
compromises for the client as the world has gone digital in distributing confidential information.
Unfortunately, mental health clinicians are largely ignorant of the full ramifications of these new initiatives.
The HIPAA (Health Insurance Portability and Accountability Act) privacy rules suggested that the bar would be
raised for clinical privacy, but, in fact, the standards were significantly lowered.”
According to Pope and Vasquez (2011, pp. 41-55),
“Technology creates new ways for us to connect with our patients. Geographic barriers fall. Relationships take
new forms. We may start and end therapy without ever being together in the same room with the patient…
But the benefits come with costs, risks, and occasional disasters. Digital technologies take confidential
information that was once confined to handwriting in a paper chart kept under lock and key and spread it over
electronic networks.”
As a very simple example, say a client texts you to say she is going to be late for her scheduled
session with you. You respond, acknowledging the message. What has happened here, in the
context of this tiresomely routine exchange? You and your client have just established a digital
record of your appointment that will reside forever on some electronic medium somewhere.
Is this a problem? Maybe not, but even the fact that a therapeutic relationship exists is part of
a confidential record. But the client did it to herself, right? She sent you the text. Again,
maybe, but you gave her your cell phone number and you responded to her text. Are these
forms of electronic communication described and discussed in your informed consent
process? Do you have reasonable protections in place?
Moving on from this seemingly innocuous example, it gets much worse. An electronic medical record is misdirected to
an unintended party. An email containing confidential information is accidentally directed to a group of inappropriate
recipients. A thoughtless Facebook posting broadcasts items of personal health information to the global audience. A
webcam in a therapist’s office is unintentionally left on during a therapy session. A confidential record stored on a cloud
storage site is compromised when the site is hacked. Therapists who are parties to such actions – whether through lack
of attention or inadequate training – are participants in digital errors that can damage clients.
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Such occurrences are violations of ethical standards and, in some cases, of legal requirements. But do they constitute
medical errors in behavioral health? Yes – certainly – if the provider failed to protect the client’s privacy, whether or not
damage to the client occurred. As noted elsewhere in this course, the Institute of Medicine (IOM) defines a medical
error as: "The failure to complete a planned action as intended or the use of a wrong plan to achieve an aim." In
psychotherapy, planned actions are always intended to be private and confidential.
So, what can be done to avoid the types of errors that can result from the use, misuse, or misunderstanding of digital
communications technology?
The following are questions posed by Pope and Vasquez (2011, p. 56) for therapists to ponder when considering
introducing new forms technology into their daily practice routine.
•
If you use social networking media like Facebook, Twitter or others, does that medium form a link between you
and any of your patients or your patients’ families? If so, how might it affect the process of therapy or the
therapeutic relationship?
o
•
Are you competent to provide services through digital media?
o
•
Issues to be considered here are the necessity of carefully thinking through the potential ramifications
of introducing new processes, studying the available research, dealing with informed consent issues, and
assuring the accuracy and security of clinical documentation.
For example, Standard 2.01 of the Ethical Principles of Psychologists and Code of Conduct (APA, 2010)
requires that psychologist provide services only within the boundaries of their competence. Before
attempting to utilize technology like email, website communication, web cameras or microphones,
clinicians must have adequate training. Opportunities for error abound.
Are you aware of the relevant laws and regulations governing the use of digital media in providing clinical
services?
o
This is particularly complex if the therapist and the client are in different states or provinces. Licensing
boards in both jurisdictions should be contacted for guidance. This may also be an item to check with
one’s liability insurance carrier.
•
Are you aware of emerging research on clinical services offered through digital media?
•
Are you aware of the professional guidelines for teletherapy, Internet therapy, and other clinical services
provided through digital media?
o
On his website, Ken Pope offers a page of links to therapy, counseling, forensic, and related ethics (and
practice) codes developed by a very extensive list of professional organizations. The page:
http://kspope.com/ethcodes/index.php
As a final consideration, it must be acknowledged that there is some risk inherent in certain everyday practices. We all
know that email is not secure. We all understand that cell phone calls can be intercepted and/or recorded. We have all
learned that electronic medical records are occasionally misplaced or misdirected. Two important parts of the
prevention of medical errors in behavioral health are (1) having systems in place to minimize the risk and (2) utilizing a
very robust informed consent process in which therapist and client together consider, discuss, and agree to the
conditions and limitations of therapy.
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Disciplinary Action
Pope and Vasquez (2007) offer reasons for disciplinary actions from the Association of State and Provincial Psychology
Boards (ASPPB) dating back twenty years to the end of 2005. The following is a partial list from that source. All of these
categories of unethical conduct can lead to errors in practice and damage to clients, some more overtly than others.
Reason for Disciplinary Action
Number Disciplined
Sexual/Dual relationship
866
Negligent, unethical, unprofessional practices
845
Improper or inadequate record keeping
155
Failure to get CE credits
135
Breach of confidentiality
129
Working while impaired
113
Fraudulent acts
175
Fraud in license application
51
Inadequate or improper supervision
124
Conviction of a crime
265
Total
2,858
Error Reduction and Prevention
Begin with Mandatory Error Reporting
How can healthcare professionals and facilities make an impact on the problem of medical errors at the grass roots
level? One of the most controversial recommendations by the IOM was to require mandatory error reporting. Many
experts suggest that reducing medical errors is difficult unless the scope and severity of the errors is known. But
mandatory reporting is frightening to many because the present system in the United States identifies and takes action
against the person committing the error. Action may include anything from a reprimand to training, disciplinary action
by a state licensing board, suspension or firing from work, and even litigation from a malpractice suit. These
consequences encourage people to under report or hide and not report errors at all.
In addition, the media can affect the reputation of a facility or health professional’s practice when they report “near
misses.” Unhappy people often tell everyone they know. Healthcare is then put on the defensive. The first response is
typically to get rid of the “bad apple” resulting in a feeling of “losing no matter what you do.” All of these factors keep
errors from being reported.
Human Error versus System Error
There are two ways to view the occurrence of a medical error. One is to blame the individual (name, shame, and blame)
and another quite different view is to analyze the system and determine what caused the error to occur. Human error is
often the result of system failure. According to the IOM, most errors are not due to individual negligence or misconduct
but to system breakdown. Instead of blaming individuals, organizations need to look hard at improving the delivery of
care, remembering that most health care professionals are competent but are vulnerable to mistakes just by being
human.
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Although it may be human to make mistakes, it’s also human nature to find better solutions. It no longer works to simply
remind people to be attentive and careful. Mistakes are made by all workers. Exemplary employees are not excluded.
James Reason in the British Medical Journal (2000) says “we cannot change the human condition but we can change the
conditions under which humans work.” He states that in the field of aviation maintenance (a hands-on activity that is
similar to medical practice in many respects) some 90% of errors were judged to be blameless. In the system approach,
different individuals make similar mistakes because of the system context, which leads to the error. A system that
includes barriers, safeguards, and defenses will reduce errors by all individuals who work in the system.
Focus on WHAT Caused the Error, Not WHO
Instead of human error, the focus must be on what we do as professionals and how we do it. This concept calls for a
redefining of culture where the focus is not on WHO caused the error but WHAT went wrong in the process. For
example, in a five-step process, you have five possibilities for error. There is a need to create safer systems that help
eliminate the possibility of failure for the health professional and provide consistent quality care to the patient.
The goal of the redefined culture is a non-punitive, blameless one where reporting of errors is the norm. In order to
develop voluntary reporting of medical errors, there must be a culture of safety where the system encourages error
reporting, accountability, honesty, and rapid settlement of injuries, seeing the injuries as system problems.
Timely reporting of errors is crucial for determining where the system failed and correcting the delivery of care process.
This culture calls for leadership to engage and provide continuing education with the focus on system improvement
along with the support of staff involved in errors.
Getting to the Root of the Error
What should happen once a medical error has occurred? An
investigation or what is referred to, as a root cause analysis is the
part of the process that reviews the error and identifies policies and
procedures to improve care. A root cause analysis should also
evaluate near misses and adverse events. The goal is to generate
strategies for prevention while nurturing a culture of safety within
the organization. The concept of the root cause analysis is to
identify, analyze and correct the events leading to errors or error
potentials. When the failure is corrected, it should prevent the
adverse event from reoccurring. This analysis includes an in-depth
look at small and even inconsequential factors in a system that
when looked at together may be a factor in the overall cause of
errors.
An objective view without bias is necessary to identify all possible root causes with a focus on the system processes
versus an individual. The analysis team questions all those involved in the system or process including those people
directly involved in the error, those closest to the process being evaluated, the leadership of the process or system,
others from related technologies and unbiased, objective, unrelated members of the organization.
There are two types of root cause analysis:
1. Proactive: studying potential areas where errors could likely occur and putting into action a plan to
prevent them.
2. Reactive: occurring after the fact or after the error has occurred. This includes defining the error, asking
why, and then repeatedly asking why until all possibilities for the error are exhausted.
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The reactive plan should include not only a sequence of events leading up to the error but a flow chart and time table of
the events that should have taken place to prevent it. A close look at the differences between the proactive and reactive
analyses helps to identify and pinpoint possible root causes. Following the root cause analysis is the development of a
plan with measurable actions that includes improving patient safety, as well as continuing education in the use of
current and best practice knowledge. The Joint Commission has a detailed framework for this analysis and plan on their
website (see the resources section at the end of this course).
The retrospective process of root cause analysis asks three questions:
1. What happened?
2. Why did it happen?
3. What can be done to prevent it from happening again?
For example, if a psychologist failed to reach a proper diagnosis and develop an appropriate treatment plan, resulting in
some damage to a client, the root cause analysis would attempt to discover exactly what happened, why, and how it
could be avoided in the future.
What happened? What was the psychologist’s mistaken diagnosis and what happened to the client as a consequence?
Why did it happen? Was the failure to diagnose a problem of competence, training, supervision, overload, impairment,
attention to detail, or something else? Why was the psychologist practicing under conditions that allowed the mistake to
occur?
What can be done to prevent it from happening again? What steps would the psychologist involved (as well as other
practitioners) need to take in order to prevent such errors from happening in the future? This would include specific
recommendations such as peer consultation, supervision, continuing education, or other such measures.
Errors of Omission
Errors of omission are also included as medical errors. An error of omission results when actions are not taken to
prevent injury to patients and the injury occurs. Lack of prevention and the resultant injury are considered a medical
error. Omission of necessary steps is the most common human error made. Characteristics prone to omissions:
•
•
•
•
The higher the short term memory demands, the greater the chance a step will be omitted
Isolated procedural steps where obvious cueing is missing
Tasks near the end of a sequence
Tasks that follow an unexpected interruption
Here are a few examples of errors of omission in behavioral health:
1. You send a secure electronic transmission of records incorrectly due to failure to complete a number of
sequential steps due to fatigue, inattention, or an interruption. The outcome might be either a failed
transmission, or an unsecured one.
2. You hurriedly finish a Skype conversation with a colleague just as your next client walks in the door. You start
your therapy session, forgetting to turn off the web cam and microphone on your computer.
3. You have a quick word with your office manager on the office intercom. Two minutes into your next therapy
session, your office manager informs you that you have left the intercom in your office on and she can hear
what is being said.
We generally have these systems secured, but it is when we are fatigued or rushed that procedures begin to break
down.
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Identification and Measurement of Medical Errors
The Global Trigger Tool
According to Classen et al. in Health Affairs (2011), identification and measurement of medical errors is imperative for
patient safety, accountability, prioritizing problems, and testing for interventions that work. Adverse events occurred in
one-third of hospital admissions. The study compared three methods to detect adverse events in hospitalized patients,
using the same patient sample set from three leading hospitals.
The results indicated that the adverse event detection methods commonly used in the United States-voluntary reporting
and the Agency for Healthcare Research and Quality's Patient Safety Indicators-fared very poorly compared to other
methods and missed 90 percent of the adverse events. The Global Trigger Tool found at least ten times more confirmed,
serious events than these other methods.
•
•
•
Triggers are algorithms that use electronic patient data to identify patterns consistent with a possible adverse
event (AE).
o e.g. the combination of a lab value threshold and an active prescription
Global vs. AE specific trigger
o Flags the chart for the suspicion of occurrence of any AE or the occurrence of a specific AE
Interventionist triggers
o Gives providers a chance to respond and avoid alert overload
2013 National Patient Safety Goals: Behavioral Health Care
The following goals were adapted from the Joint Commission website (http://www.jointcommission.org/). The goals are
a very short, easy-to-read version of the detailed goals for behavioral health that can be found at
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/.
The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care
safety and how to solve them.
Identify clients correctly
NPSG.01.01.01
Use at least two ways to identify clients. For example, use the client’s name and date of birth. This is done to
make sure that each client gets the correct medication and treatment.
Use medicines safely
NPSG.03.06.01
Record and pass along correct information about a client’s medicines. Find out what medicines the client is
taking. Compare those medicines to new medicines given to the client. Make sure the client knows which
medicines to take when they are at home. Tell the client it is important to bring their up-to-date list of medicines
every time they visit a doctor.
Prevent infection
NPSG.07.01.01
Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health
Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
Identify client safety risks
NPSG.15.01.01
Find out which clients are most likely to try to commit suicide.
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The Florida Statutes
Although there is no nationwide regulation for mandatory reporting of medical errors, some state statutes including
Florida do require it. The Florida Statutes Title XXIX Public Health, Chapter 395.0197 Hospital Licensing and Regulation,
Part I Hospital and Other Licensed Facilities state: [Florida Statutes: http://www.leg.state.fl.us/Statutes]
(6)(a) Each licensed facility subject to this section shall submit an
annual report to the agency summarizing the incident reports that
have been filed in the facility for that year. The report shall include:
1) The total number of adverse incidents.
2) A listing, by category, of the types of operations, diagnostic or
treatment procedures, or other actions causing the injuries, and
the number of incidents occurring within each category.
3) A listing, by category, of the types of injuries caused and the
number of incidents occurring within each category.
4) A code number using the health care professional's licensure number and a separate code number identifying all
other individuals directly involved in adverse incidents to patients, the relationship of the individual to the licensed
facility, and the number of incidents in which each individual has been directly involved. Each licensed facility shall
maintain names of the health care professionals and individuals identified by code numbers for purposes of this
section.
5) A description of all malpractice claims filed against the licensed facility, including the total number of pending and
closed claims and the nature of the incident which led to, the persons involved in, and the status and disposition of
each claim. Each report shall update status and disposition for all prior reports.
6) The licensed facility shall notify the agency no later than 1 business day after the risk manager or his or her designee
has received a report pursuant to paragraph (1)(d) and can determine within 1 business day that any of the
following adverse incidents has occurred, whether occurring in the licensed facility or arising from health care prior
to admission in the licensed facility:
a) The death of a patient;
b) Brain or spinal damage to a patient;
c) The performance of a surgical procedure on the wrong patient;
d) The performance of a wrong-site surgical procedure;
e) The performance of a wrong surgical procedure.
There are other aspects of mandatory reporting that concern errors that can have very serious consequences in the
practice of behavioral health: reporting suspected child abuse and duty to warn when dealing with dangerous clients.
Mandatory Reporting of Suspected Child Abuse
Reporting of child abuse by professionals and others is mandatory in every state in the union. Failure to do so would be
a serious medical error of omission (as well as an unethical and illegal act) that could lead to very serious danger to the
child. All 50 states, the District of Columbia, Puerto Rico, and the US territories have laws that mandate reporting of child
maltreatment. Some states use more specific definitions of who is a mandated reporter. Others opt for more flexible
verbiage is order to cast a wider net. In all states, healthcare providers are mandated reporters.
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In addition, all mandatory reporting laws use intentionally vague descriptors of the level of concern or certainty the
reporter must have in order to initiate a report. Some laws specify “cause to believe…” or “suspect…” in order to achieve
the threshold for reporting. In order to encourage wider compliance, all mandatory laws include good faith exemptions
from civil prosecution if it is ultimately determined that maltreatment cannot be substantiated.
In the State of Florida, a new law took effect on October 1, 2012 that was touted as the toughest in the nation, called
the “Protection of Vulnerable Persons Act.” It goes far beyond prior laws, which required reporting only when the
suspected abuser was a parent or caretaker. For the first time, the new law makes reporting of child-on-child abuse
mandatory. It applies to any abuser, even those who are children themselves. Children 12 and under who are deemed
perpetrators will be referred for treatment and therapy, but those 13 and up will be referred to law enforcement.
Individuals who fail to report abuse and neglect face felony prosecution and fines up to $5,000.
Coming in the wake of the Penn State scandal, the new law also stipulates that colleges and universities that "knowingly
and willfully" fail to report suspected child abuse, abandonment or neglect — or prevent another person from doing so
— now face fines of up to $1 million for each incident.
For other states, please refer to the Child Welfare Information Gateway report: Mandatory Reporters of Child Abuse and
Neglect: Summary of State Laws, which can be found online at:
http://www.childwelfare.gov/systemwide/laws_policies/statutes/manda.cfm
The take-home point here is that this is a prime example of an area in which failure to adhere to legal and ethical
mandates is also a very serious medical error in behavioral health practice.
Duty to Warn: Dealing with Dangerous Clients
One of the complex issues that confront therapists in the area of
privacy and confidentiality as they relate to the prevention of
medical errors is the question of what to do about clients who
appear to pose a danger to themselves and others.
The APA Ethics Code (APA, 1992) Section 4 (Privacy and
Confidentiality) provides guidance on this subject. The code allows
psychologists to disclose confidential information when permitted
by law, to obtain a needed professional consultation, or to protect
one’s self, the client, or others from harm.
4.05 Disclosures
(a) Psychologists may disclose confidential information with
the appropriate consent of the organizational client, the
individual client/patient, or another legally authorized
person on behalf of the client/patient unless prohibited by
law.
(b) Psychologists disclose confidential information without the
consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to (1)
provide needed professional services; (2) obtain appropriate professional consultations; (3) protect the
client/patient, psychologist, or others from harm; or (4) obtain payment for services from a client/patient, in
which instance disclosure is limited to the minimum that is necessary to achieve the purpose. (See also Standard
6.04e, Fees and Financial Arrangements.)
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The NASW Code of Ethics (NASW, 2008) provides for similar exceptions in service to the safety of the client or others:
1.07 Privacy and Confidentiality
(c) Social workers should protect the confidentiality of all information obtained in the course of professional
service, except for compelling professional reasons. The general expectation that social workers will keep
information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and
imminent harm to a client or other identifiable person. In all instances, social workers should disclose the least
amount of confidential information necessary to achieve the desired purpose; only information that is directly
relevant to the purpose for which the disclosure is made should be revealed.
NBCC Code of Ethics (NBCC, 2005):
Section B: Counseling Relationship
(4) When a client's condition indicates that there is a clear and imminent danger to the client or others, the certified
counselor must take reasonable action to inform potential victims and/or inform responsible authorities.
Consultation with other professionals must be used when possible. The assumption of responsibility for the
client's behavior must be taken only after careful deliberation, and the client must be involved in the resumption
of responsibility as quickly as possible.
One of the landmark rulings in this area of duty to warn is the Tarasoff Ruling: Tarasoff v. Regents of U of CA., 17 Cal.3d
425, 444 (1976). In 1976, the California Supreme Court Justices made some important rulings that may have changed
forever the responsibilities for all mental health professionals in all states.
Tarasoff (1976) originally declared that in order to breach the dangerous patient’s confidentiality, all of the following
must be present:
1. Communicated to psychotherapist directly by patient - the threat must come directly from the patient to the
psychologist unless it is an incapacitated patient or a minor patient
2. Serious threat of physical harm which is imminent - a proper dangerousness assessment must be used for evaluation
3. Reasonably identifiable victim - the justices said: if the psychotherapist can determine who the potential victim is
“with a moment’s reflection” then the third determinant of Tarasoff is met. These justices went on to say once the
threat reaches the threshold of the three requirements above, then the psychologists should:



Warn potential victim(s)
Notify authorities (this generally means the police, sheriff, DCFS, 911, etc.)
Take steps to prevent the threatened danger (Stromberg et al, 1988):
“The most important point is that … psychologists’ duties are not limited to a ‘duty to warn,’ but broadly include taking
all steps which constitute reasonable care [taken] to protect the intended victim” (Stromberg et al, 1988, p. 520-521).
The California Supreme Court Justices stated that psychotherapists are to “take whatever other steps reasonably
necessary under the circumstances.”
Each state has its own laws regarding duty to warn and when to breach confidentiality in order to protect the public
welfare. Therapists are required to know these laws in order to practice ethically.
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An example is Chapter 491 of the Florida Statutes, which details the laws and rules governing the practice of Clinical
Social Work, Marriage and Family Therapy, and Mental Health Counseling in the State of Florida. Chapter 491 includes
the following section:
491.0147 Confidentiality and privileged communications.--Any communication between any person licensed or certified
under this chapter and her or his patient or client shall be confidential. This secrecy may be waived under the following
conditions:
(1) When the person licensed or certified under this chapter is a party defendant to a civil, criminal, or disciplinary
action arising from a complaint filed by the patient or client, in which case the waiver shall be limited to that
action.
(2) When the patient or client agrees to the waiver, in writing, or, when more than one person in a family is
receiving therapy, when each family member agrees to the waiver, in writing.
(3) When, in the clinical judgment of the person licensed or certified under this chapter, there is a clear and
immediate probability of physical harm to the patient or client, to other individuals, or to society and the person
licensed or certified under this chapter communicates the information only to the potential victim, appropriate
family member, or law enforcement or other appropriate authorities. There shall be no liability on the part of,
and no cause of action of any nature shall arise against, a person licensed or certified under this chapter for the
disclosure of otherwise confidential communications under this subsection.
http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=04000499/0491/Sections/0491.0147.html
For psychologists in Florida, the following statute applies:
490.0147 Confidentiality and privileged communications.--Any communication between any person licensed under this
chapter and her or his patient or client shall be confidential. This privilege may be waived under the following
conditions:
(1) When the person licensed under this chapter is a party defendant to a civil, criminal, or disciplinary action arising
from a complaint filed by the patient or client, in which case the waiver shall be limited to that action.
(2) When the patient or client agrees to the waiver, in writing, or when more than one person in a family is
receiving therapy, when each family member agrees to the waiver, in writing.
(3) When there is a clear and immediate probability of physical harm to the patient or client, to other individuals, or
to society and the person licensed under this chapter communicates the information only to the potential
victim, appropriate family member, or law enforcement or other appropriate authorities.
http://www.flsenate.gov/Laws/Statutes/2012/490.0147
Patients’ Right to Know
In 2005, Florida passed the “Patients’ Right to Know about Adverse Medical Incidents Act,” Florida Statutes XXIX, Public
Health Chapter 381, Statute 381.028. This purpose of this act is to allow patients access to records of adverse medical
incidents when these records were made or received in the course of business by a health care facility or provider.
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According to the statute, the definition of adverse medical incident is:
(b)"Adverse medical incident" means medical negligence, intentional misconduct, and any other act, neglect, or default
of a health care facility or health care provider which caused or could have caused injury to or the death of a patient,
including, but not limited to, those incidents that are required by state or federal law to be reported to any
governmental agency or body, incidents that are reported to any governmental agency or body, and incidents that are
reported to or reviewed by any health care facility peer review, risk management, quality assurance, credentials, or
similar committee or any representative of any such committee.
Florida Statutes: http://www.flsenate.gov/Laws/Statutes/2010/381.028
Ethics, Medical Errors, and Mental Health Professionals
What role do ethics codes play in preventing medical errors in the
practice of psychotherapy? Koocher and Keith-Spiegel (2008) note
that there are several purposes of ethics codes: “A code…creates an
implied social contract that purports to balance professional privilege
with responsibility and a commitment to consumer welfare…They set
aspirations and expectations for members, reduce internal bickering
about what is and is not proper conduct, and serve as tools for
licensure boards, civil litigants, and other formal mechanisms of
redress to cite in sanctioning and defending professional conduct” (p.
42). Thus, promoting the best interest of clients, setting standards to
which therapists should aspire, preventing practice errors, serving as
a reference in ethical or legal proceedings as well as providing general guidelines as to how dilemmas can be resolved
are what make ethics codes useful.
A number of moral principles appear in the various codes of ethics. Together, they guide the professional conduct of
mental health professionals. Among them are nonmaleficence, fidelity, beneficence, and veracity. Each of these
principles has a bearing on the prevention of medical errors.
Nonmaleficence, essentially the requirement to “do no harm,” is a direct challenge to psychotherapists to do whatever
is necessary to avoid causing harm to their clients. Although most therapists comprehend the impropriety of overtly
harmful acts like engaging in a sexual relationship with a client, Sperry (2007) notes that not all harm done to clients is
intentional. As such, therapists need to be proactively cognizant of how they could inflict unintended harm to clients and
take measures to prevent the occurrence of potentially harmful acts.
The word “harm” is frequently thought of as an extreme negative action inflicted on another person, like physical assault
or emotional degradation. However, given that therapists have a disproportionate amount of power in the counseling
relationship (Remley & Herlihy, 2007; Sommers-Flanagan & Sommers-Flanagan, 2007), even a subtle gesture like sighing
when a client tells you something that you think is far-fetched could be interpreted by the client as an emotional bullet.
Thus, the principle of nonmaleficence underscores the importance of not inflicting even unintentional harm.
Beneficence, which is a more active concept that nonmaleficence, means taking positive, intentional steps to promote
and protect the welfare of the client. Fidelity means honoring one’s commitments and promises. For therapists, it
involves continuing to provide services to clients during good times and bad, even when there are differences between
therapist and client. Finally, veracity – truthfulness in all aspects of therapy – dictates that therapists assure that the
client’s trust is well founded so that a functioning therapeutic relationship can evolve. All of these principles are relevant
to the prevention of errors in psychotherapy.
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Admission of Errors
Honest and open disclosure and discussion can preserve the patient’s trust in the
health care professional. Many times, patients are already suspicious that
something has gone wrong and consider it an act of respect to them for the
physician or health care professional to bring it out in the open. Patients then get a
more realistic view of the limitations of health care. In addition, in-depth discussions
may strengthen trust and can communicate mutual respect. However, admission of
errors is difficult for most health care professionals. Although not typically
addressed in school or other training, Rosner (2000) says that telling the truth
should be the norm, not unique, and is the sign of a healthier health care system.
What remains unclear, according to Rosner and his associates is whether there is an
obligation to report minor errors. Minor errors are referred to as those without material consequence to the patient’s
well-being. Most patients want to be told about all errors, even minor ones.
What should you do if you recognize that you have made an error, violated a boundary or a licensing board rule, or
committed an act that is or might be a medical error? Zuckerman (2009) suggests the following procedures:
1) Consult immediately with a peer, but be aware that these conversations are not privileged. Use “hypothetical's”
such as “What would you do in a case of ….?”
2) Clarify the facts, create a chronology, recall your perceptions, what the client did, etc.
3) Clarify your responsibilities, your judgments, and what you contributed.
4) Only then can you decide if you will apologize.
5) Document the consultations and conclusions.
Consider apologizing:
1) If the complaint is valid, accepting responsibility, apologizing, and trying to make things right, in consultation
with experts and your lawyer, should be considered.
2) When there is a bad outcome, a rupture of the relationship, or a significant error, the patient and family want to
know what lead up to it. They have a right to this information.
3) Professionals have an ethical duty to inform them. Professionals are often afraid that telling the truth will lead to
a complaint or malpractice suit against them or others and so remain silent or evasive.
4) About 35 states have ‘I’m sorry‘ laws so what you tell the patient or family cannot be used later in a malpractice
suit. For more see: http://virtualmentor.ama-assn.org/2007/04/hlaw1-0704.html and
http://www.perfectapology.com/medical-errors.html. Note: These laws apply only to physicians at present.
5) What research there is on apologizing in these circumstances reinforces doing it. Remember complaints are not
highly correlated with bad outcomes but are with dissatisfaction, strong negative emotions, and poor or
ruptured relationships.
6) Consider your and the client’s feelings fully. They are most often an intense mixture of fear, anger, hurt, etc.
Consider your peer’s feelings but do not be bound by their recommendations.
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Recognition of Errors by another Professional
What about the obligation of a health care professional when he or she recognizes the error of another health care
professional? These can be difficult situations. Nevertheless, this is an important part of protecting clients’ safety.
Several of the national professional associations contain section on the issue.
There are two sections in the APA Ethical Principles of Psychologists and Code of Conduct (APA 2002) that directly
address such situations:
1.04 Informal Resolution of Ethical Violations
When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to
resolve the issue by bringing it to the attention of that individual, if an informal resolution appears appropriate and the
intervention does not violate any confidentiality rights that may be involved.
1.05 Reporting Ethical Violations
If an apparent ethical violation has substantially harmed or is likely to substantially harm a person or organization and is
not appropriate for informal resolution under Standard 1.04, Informal Resolution of Ethical Violations, or is not resolved
properly in that fashion, psychologists take further action appropriate to the situation. Such action might include referral
to state or national committees on professional ethics, to state licensing boards, or to the appropriate institutional
authorities. This standard does not apply when an intervention would violate confidentiality rights or when
psychologists have been retained to review the work of another psychologist whose professional conduct is in question.
There are three sections in the NASW Code of Ethics (NASW 2010) that directly address similar situations:
2.09 Impairment of Colleagues
(a) Social workers who have direct knowledge of a social work colleague’s impairment that is due to personal
problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice
effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.
(b) Social workers who believe that a social work colleague’s impairment interferes with practice effectiveness and
that the colleague has not taken adequate steps to address the impairment should take action through
appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other
professional organizations.
2.10 Incompetence of Colleagues
(a) Social workers who have direct knowledge of a social work colleague’s incompetence should consult with that
colleague when feasible and assist the colleague in taking remedial action.
(b) Social workers who believe that a social work colleague is incompetent and has not taken adequate steps to
address the incompetence should take action through appropriate channels established by employers, agencies,
NASW, licensing and regulatory bodies, and other professional organizations.
2.11 Unethical Conduct of Colleagues
(a) Social workers should take adequate measures to discourage, prevent, expose, and correct the unethical
conduct of colleagues.
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(b) Social workers should be knowledgeable about established policies and procedures for handling concerns about
colleagues’ unethical behavior. Social workers should be familiar with national, state, and local procedures for
handling ethics complaints. These include policies and procedures created by NASW, licensing and regulatory
bodies, employers, agencies, and other professional organizations.
(c) Social workers who believe that a colleague has acted unethically should seek resolution by discussing their
concerns with the colleague when feasible and when such discussion is likely to be productive.
(d) When necessary, social workers who believe that a colleague has acted unethically should take action through
appropriate formal channels (such as contacting a state licensing board or regulatory body, an NASW committee
on inquiry, or other professional ethics committees).
(e) Social workers should defend and assist colleagues who are unjustly charged with unethical conduct.
From the Code of Ethics of the American Counseling Association (ACA 2005):
H.2. Suspected Violations - H.2.a. Ethical Behavior Expected
Counselors expect colleagues to adhere to the ACA Code of Ethics. When counselors possess knowledge that raises
doubts as to whether another counselor is acting in an ethical manner, they take appropriate action.
H.2.b. Informal Resolution
When counselors have reason to believe that another counselor is violating or has violated an ethical standard, they
attempt first to resolve the issue informally with the other counselor if feasible, provided such action does not violate
confidentiality rights that may be involved.
H.2.c. Reporting Ethical Violations
If an apparent violation has substantially harmed, or is likely to substantially harm a person or organization and is not
appropriate for informal resolution or is not resolved properly, counselors take further action appropriate to the
situation. Such action might include referral to state or national committees on professional ethics, voluntary national
certification bodies, state licensing boards, or to the appropriate institutional authorities. This standard does not apply
when an intervention would violate confidentiality rights or when counselors have been retained to review the work of
another counselor whose professional conduct is in question.
A Plan for Avoiding Medical Errors in Behavioral Health Care
1) The Importance of an Accurate Diagnosis
Making an accurate diagnosis very early in the process of psychotherapy is part of the professional standard of practice.
Zuckerman (2009) recommends use of the ICD-9-CM (International Classification of Disorders, Ninth Edition, Chapter 5
[Mental Disorders]), not the DSM, because it was made the standard by HIPAA.
Preventing treatment errors is partially a factor of precision in determining exactly what is problematic in the client’s
functioning and fashioning a systematic treatment plan to remediate it. If the diagnosis is wrong, the treatment cannot
be right. As a matter of fact, if a therapist provides the wrong treatment, the outcomes can be disastrous.
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A common example is missing a diagnosis of substance use disorder, particularly when it is complicated or masked by
other conditions. Failure to treat the substance use disorder can lead to life-threatening outcomes, either resulting from
the substance abuse itself or from treatment attempts that are unsuccessful because of the failure to make a dual
diagnosis. In cases where patients are prone to violent or self-destructive behavior, the outcomes can be fatal.
2) The Importance of Informed Consent as a Preventative Method
In two of the scenarios described earlier in this course, the failure on the part of the therapists to
complete a competent informed consent process resulted in serious difficulties for their clients. In
the case of Mr. X and Dr. Y, the client was presented with and signed an informed consent form
prior to starting treatment. However, he found out only when it was too late that his treatment
information was funneled through his managed care organization to a national data bank where it
was accessed and used to prevent him from receiving a security clearance for his job.
Using the root cause analysis system of inquiry, what happened here, why did it happen, and what could be done to
keep it from happening again?
What happened was that Mr. X was surprised after the fact that his personal information – which he thought was
privileged between him and his psychologist – turned out to be not private at all. Why did this happen? While Dr. Y did
get an informed consent form signed, he apparently did not explain it thoroughly enough that Mr. X understood that
certain aspects of his therapy were going to be reported to the MCO and that some of it could be accessed if he applied
for insurance or a security clearance in the future. If Mr. X were to give a truly “informed” consent at the onset of
therapy, this would be very important information for him to have. Dr. Y erred in not assuring that his client understood
all of the ramifications of his consent.
What could be done to keep this from happening again? The only solution is for therapists to employ an informed
consent process that involves (1) a signed form, (2) a detailed discussion in which the therapist takes steps to be sure the
client understands all of it, and (3) a detailed patient education handout for the client to take home and read later. The
forms obviously need to be carefully drafted with the overt intent of avoiding any misunderstanding. In the first
treatment session, clients are frequently overcome with distress over whatever brought them to therapy. Thus, they
may not be in an ideal frame of mind to attend to the informed consent form. The patient handout is intended to help
with this by sending them home with something they can read more carefully later. In the next session, the therapist can
return to the contents of the consent form to be sure there are no misunderstandings.
In Case # 2 from the public records of the Florida Department of Health detailed earlier in this course, the psychologist
erred even more grievously by giving the client a consent form that was not even applicable to his situation, advising
him that he had privacy rights that he did not actually have. Why did this happen? The Board of Psychology concluded
that the psychologist in question was undertaking activities for which she was not qualified by training or experience.
3) The Primacy of Protecting the Client’s Privacy and Confidentiality
The centrally important issue of privacy and confidentiality ties in closely with the discussion of informed consent. That
is, the client needs to understand from the outset exactly what the bounds of confidentiality are in the therapy he or she
is undertaking. What are the guarantees and what are the exceptions? The exceptions are probably more important
than the principles and guarantees.
Specific to the practice of marriage and family therapy is the problem of determining who “owns” the privilege in the
case of a family or a married couple. Most legal definitions specifically emphasize that ownership of the privilege – and
therefore of the right to waive it – resides with the client. Who is the client when the therapist is treating more than one
individual as the unit of therapy?
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This dilemma is particularly acute when there is an adversarial event like a divorce or a custody proceeding. Such cases
require therapists to be sufficiently informed in the ethical guidelines promulgated by their profession as well as in the
laws of the jurisdiction in which they practice. Furthermore, this is one of the areas where the result may be a conflict
between one’s ethical guidelines and the law of the land. The therapist may act in such a way as to protect the
confidentiality of the client (or clients) and the court may act in such a way as to serve the letter of the law.
In both Case # 1 and Case #3 from the public records of the Florida Department of Health, the therapists broke the trust
of their clients by revealing privileged information shared in confidence. Why did this happen? In Case #1, it is not clear
why the social worker revealed confidential information to an attorney in spite of not only not having his clients’ written
consent to do so, but even an explicit prohibition by the husband. In divorce proceedings, it is not unusual for a therapist
to be contacted by one or both of the parties’ attorneys with requests for information. At such times therapists must
scrupulously adhere to the confidentiality tenets of their ethics codes as well as to legally mandated procedures.
In Case #3, the counselor clearly had very serious boundary issues. The Board found that she was involved in an
inappropriate dual relationship with the client and also breached patient confidentiality. Many serious and damaging
errors can be avoided by maintaining appropriate professional boundaries.
4) Develop and Follow a Proactive Plan for Avoiding Practice Errors
Zuckerman (2009, p. 24) lists ways to avoid practice errors:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Make and keep protective, high quality, tailored-to-your-practice records
Tighten up your practice’s procedures
Consult with experts
Respond early and fully to any and all complaints
Attend to the client‘s expectations and outcomes
Practice at or above the standards of your discipline and community
Keep up and get quality training
Develop an ethics conscience that warns and advises you
He adds (p. 43), quoting Pope and Vasquez (2007), “ethics struggles are often
unavoidable. As psychologists, we often encounter ethical dilemmas without clear and
easy answers. We confront overwhelming needs unmatched by adequate resources,
conflicting responsibilities that seem impossible to reconcile, frustrating limits to our
understanding and interventions, and countless other challenges as we seek to help
people who come to us because they are hurting and in need, sometimes because they
are desperate and have nowhere else to turn. There is no legitimate way to avoid
these ethical struggles. They are part of our work.”
Quarto (2009, p. 15) details six steps to use in ethical decision making, which is a prime
way to avoid practice errors:
(1)
(2)
(3)
(4)
Listen to your gut
Discuss your dilemma with a significant other, colleague or supervisor
Consider how an admired friend or professional would handle this situation
Think of the dilemma from various angles and rehearse how you will follow
through with your decision
(5) Carry through with your decision with the understanding it is congruent with
the moral principles
(6) Evaluate the success of your decision and, if necessary, do things differently the next time
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5) Self-Care as a Way to Prevent Errors
The second and third questions asked in the root cause analysis process are “why did this happen?” and “what can be
done to prevent this from happening again?” Both of these questions can be at least partially answered by a number of
considerations that might fall into the category of self-care. All licensed mental health professionals have undergone
rigorous training, extensive clinical supervision, and years of experience. They are required to earn hours of continuing
education (CE) each time they renew their licenses. Some of the required CE hours are in the areas of ethics, law, and
preventing medical errors.
So how could a professional with such training and experience make mistakes like revealing confidential information to
an unauthorized party or failing to advise her client of any exceptions to confidentiality? How would it be possible to fail
to understand appropriate professional roles and boundaries? How could they make improper diagnoses, or to
inadequately assess the potential for danger, or fail to detect a medical condition presenting like a psychiatric disorder?
The first and obvious answer is that mistakes happen. To err is human. These are realities from which none of us is
exempt.
However, errors are most likely to happen when we are not at our best, possibly in a hurry or distracted. Therefore, it is
incumbent upon all professionals to do everything they can do to prevent themselves from making errors that damage
their clients. One of the things we all need to do is take care of ourselves so that we are always on our toes and can
bring to bear all of the years of training and experience we have.
If we are overworked, or stressed, or preoccupied or burned out, how can we expect that we will be able to give our full
attention to the best interests of our clients? If I am in a hurry, I might fail to spend enough time going over the fine
points of the informed consent form with my new client. If I am overcome with worry about some personal issue in my
own life, how can I block that out during the time that I need to be exclusively focused on making the proper diagnosis
and formulating an effective treatment plan for my client?
Specifically, what can be done about it? What would you advise a client
whose performance is suffering because of a failure to engage in selfcare? You might recommend time off, meditation, exercise, hobbies,
time with family and friends, and any number of other pursuits that
tend to refresh and renew. In the case of helping professionals, self-care
is not a luxury, it is a requirement.
A good rule of thumb is “Z’s twelfth law” – Over the long run, you can
only give about 10% more than you get (Zuckerman, 2009, p. 77).
Conclusion
As health care professionals, we can help reduce medical errors and improve patient care by being accountable,
reporting errors, working to create safer health care systems, and staying up-to-date with the latest evidence-based
practice while empowering our patients and clients with information they can use to obtain better care. Remember, to
err is human. It’s what we do before and after the error that determines risk.
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Glossary
Action plan: designed after completion of the root cause analysis, this plan identifies the strategies that an organization
intends to implement to reduce the risk of similar errors in the future.
Adverse drug event: an incident where the use of a medication or a special nutritional product (for example, dietary
supplement or infant formula) results in an adverse patient outcome.
Adverse event: An adverse event is defined by the IOM as "an injury caused by medical management rather than by the
underlying disease or condition of the patient." Adverse events resulting in medical errors are considered
preventable adverse events. Adverse events are undesirable and typically unanticipated such as a patient death
or a patient fall even if there is no permanent effect on the patient.
Beneficence: keeping the best interests of clients in mind and behaving in a manner that benefits them.
Change analysis: Looks at the differences between the expected and actual performance of a process.
Duty to Warn: the complex issues that confront therapists in the area of privacy and confidentiality as they relate to the
question of what to do about clients who appear to pose a danger to themselves and others.
Error of commission: An error that occurs as a result of an action taken.
Error of omission: An error that occurs as a result of an action not taken.
ICD-9-CM: the (International Classification of Disorders, Ninth Edition.
Informed consent: the discussion and signed form that takes place between therapist and client in the first session,
outlining such issues as limits of confidentiality, billing and fees, risks and benefits of therapy, etc.
Medical error: Defined by the IOM as "the failure to complete a planned action as intended or the use of a wrong plan
to achieve an aim." The error occurs in either the planning stage or the execution stage.
Near Miss: A situation that could have resulted in an accident or illness but did not due to competent action or chance.
Nonmaleficence: the ethical principle that challenges professionals to “do no harm,” specifically, to avoid engaging in
behaviors that could potentially harm clients.
Privileged communication: under Florida law, any communication between any person licensed under mental health
licensure acts and her or his patient or client shall be confidential. This privilege may be waived under certain
specified conditions.
Root cause: The fundamental reason for the failure of a process.
Root cause analysis: Identifying the factor(s) that affect differences in performance.
Sentinel event: An unexpected occurrence, which involves death or serious physical or psychological injury or an event
with the risk of a sentinel event. These events are referred to as "sentinel" because they indicate the need for
immediate investigation and response.
Tarasoff Ruling: the legal precedent of the duty to warn concept in Tarasoff v. Regents of the University of California
(1976).
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Online Resources
ACA Code of Ethics: http://www.cacounseling.org/standards.pdf
APA Code of Ethics: http://www.apa.org/ethics/code/index.aspx
NASW Code of Ethics: http://www.socialworkers.org/pubs/code/default.asp
NBCC Code of Ethics: http://www.nbcc.org/assets/ethics/nbcc-codeofethics.pdf
Conditional Confidentiality – The Center for Ethical Practice: http://www.centerforethicalpractice.org/wpcontent/uploads/2010/03/cep_book_FLYER.pdf
Florida Statutes Online: http://www.leg.state.fl.us/Statutes/index.cfm
Florida Statutes, 2012, Chapter 39: Mandatory reports of child abuse:
http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=00000099/0039/Sections/0039.201.html
Florida Statutes, Chapter 490, Psychological Services:
http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0490/0490.html
Florida Statutes, Chapter 491, Clinical, Counseling, and Psychotherapy Services:
http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=04000499/0491/0491ContentsIndex.html&StatuteYear=2012&Title=-%3E2012-%3EChapter%20491
Food and Drug Administration: http://www.fda.gov/
CDC Hand Hygiene Recommendations: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm
HealthGrades: http://www.healthgrades.com
Joint Commission on the Accreditation of Health Care Organizations (The Joint Commission):
http://www.jointcommission.org/
“I’m Sorry” Laws: http://virtualmentor.ama-assn.org/2007/04/hlaw1-0704.html
National Center for Patient Safety: http://www.patientsafety.gov/
National Committee for Quality Assurance: http://www.ncqa.org
National Guidelines Clearinghouse: http://www.guideline.gov
PerfectApology.com: http://www.perfectapology.com/medical-errors.html
The Agency for Healthcare Research and Quality: http://www.ahcpr.gov/
The National Academy of Sciences Institute of Medicine: http://www.iom.edu/
The National Patient Safety Foundation: http://www.npsf.org
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