Prevention of Medical Errors

1.  Identify how and when to refer patients for further evaluation and or medication.
2.  Recognize and  identify the symptoms and sources of burn-out and countertransference and how to handle them properly.
3.  Know and understand the meaning of laws pertaining to the welfare of your patients as well as the rights of patients.
4.  Identify and apply the mandatory reporting laws.
5.  Know different methods which are used to assess for suicide and understand their limitations.
6.  Understand the importance of proper record-keeping particularly regarding how HIPAA applies to you.
7.  How to evaluate the best methods to provide yourself and your patient with a safe environment while working with dangerous patients.

This course is not approved by the Florida Board of Clinical Social Work, Marriage and Family Therapy, Mental Health Counseling and the Florida Board of Nursing.

This course is approved by the Florida Board of Psychology for Psychologists 'Prevention of Medical Errors' continuing education credit.

Common Medical Errors and Ways to Avoid Them

 Preach of Confidentiality

When a patient enters our office and psychotherapy begins, everything which is said or done by that patient, with few exceptions, are confidential. The patient holds the privilege to release the confidential information in legal proceedings. While you may object to the patient using these records, you must have solid grounds for your objection. While these are quite variable, generally patients can request and use their records in any way they please. In some instances, a legal guardian or conservator may hold the privilege if the patient is unable to do so. If the patient dies, their privilege passes to the patient's personal representative who handles legal affairs.

The holder of the privilege also has the right to read all information in his or her file with the exception of your personal notes which belong solely to you. Some psychologists find this requires them to keep separate files so their personal notes do not become part of the patient's legal record. Your patient can read all notes which have their identifying information, diagnosis, treatment plan, prognosis, and other information including billing and information from other sources which you have included in the file such as notes from other physicians and hospitals. Any spare notes in the patient's file also have information which must be passed to the patient. All information in HIPAA notes are the patient's property and must be released. The file is the property of the clinician so copies must be made if the patient requests a copy of their file.

It is your responsibility to maintain the confidentiality of the records. Patient records should be kept in locked containers except when in use. They should be shredded when they are discarded to avoid the potential of having the notes fall into the hands of others. Office staff and others who handle the files should be made aware of the importance of confidentiality. Office staff, filing clerks, billing agencies, and others do not have the same burden of confidentiality as does the psychologist. However, it is the responsibility of the psychologist to inform the staff about the importance of confidentiality and to take reasonable action to be certain that staff does not violate the patient's confidentiality. While this is a solid part of HIPAA, it seems to be regularly violated by clerks and other office staff.

Medical Error: Failure to disclose Harm to Others

Case Law Example:

Reasons for Divulging Confidential Information 1976, important case law was made in California which is now followed throughout the United States. A romantic young man, Prosinjit Podder, from India, fell madly in love with Tatiana Tarasoff who did not reciprocate his desire. He confessed his intention to cause her bodily harm to his psychologist at a clinic at UC Berkley. He subsequently murdered her. The unfortunate psychologist had followed the law which until then required psychologists to keep all information from patients confidential and to disclose threats only to the intended victim. The case came to be known by the name of the murdered young woman and the defendant was the Regents of U of C so he is never named. The California Supreme Court determined that confidentiality laws did not apply when the following rules are met.

1. The threat must be communicated to the psychotherapist directly by the patient.
2. Serious threat of physical harm is imminent.
3. The potential victim must be reasonably identifiable.

In this case, the psychotherapist must:

1. Warn any and all potential victims.
2. Notify authorities including the police, sheriff, or call 911.
3. Take steps of some sort to prevent the threatened danger. law has continued to add to the confusion about when Tarasoff  applies. One case found it applied when property was threatened, another found it applied when there was no overt threat but a history of violence, in another case Tarasoff was found to apply to communicating threat of suicide to subsequent caretakers.

Under Tarasoff, the psychologist has the duty to both warn and protect potential victims.
A psychologist is also required to breach confidentiality when a patient threatens to harm another person but there is no imminent danger or the victim's identity is unknown. In this case, however, the therapist is to take steps to prevent danger but is not to notify authorities or the potential victim.

Psychologists are also required to breach confidentiality if the patient is in danger of committing suicide and is to take steps to prevent the danger from occurring. In most cases, this requires the therapist to hospitalize the patient.

The courts have required that therapists be able to predict when a patient will act on their impulses and cause bodily harm to themselves or others. Therapists, regardless of their experience are unable to predict when or if someone will be dangerous. Research has consistently borne out that therapists cannot predict violence above the level of chance (Stromberg et al., 1988; Bednar et al., 1991; Otto, 1992; Simon, 2001).

Some traits are more likely than others to predict violence, with the most robust being a history of violence (Simon, 2001), male gender (Simon, 2001), substance abuse (Stromberg et al., 1988).Peterson et al., 1983 has shown some positive results in identifying people who are likely to commit suicide. The scaling is simple and quick on the SAD PERSONS test and the results have been replicated (Campbell, 2003; Juhnke, 1994,1996).

Florida  “Duty to Protect” Act.

The Florida Mental Health Act (Title XXIX Chapter 394) This act is for purposes of involuntary confinement of a person who is deemed to be a danger to self/others. (394.463).   The criteria for involuntary confinement are as follows:

Criteria- A person may be taken to a receiving facility for involuntary examination if there is reason to believe that he or she is mentally ill and because of his or her mental illness.
1. The person has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination; or.
2. The person is unable to determine for himself or herself whether examination is necessary; and
3. Without care or treatment, the person is likely to suffer from neglect or refuse to care for himself or herself; such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services or
4. There is a substantial likelihood that without care or treatment the person will cause serious bodily harm to himself or herself or others in the near future, as evidenced by recent behavior.

Florida Child Abuse Reporting:

Failure to report suspected child abuse or neglect is a medical error of omission.  The following must be reported in Florida.
Any person, including a health care provider, who knows or has reasonable cause to suspect child abuse, abandonment or neglect by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, must report such knowledge or suspicion to the Department of Children and Families (DCF) Central Abuse Hotline. F.S. 39.201(1))
HIPAA Compliance for reporting child abuse: A health care provider may disclose PHI to a public authority or other appropriate government authority authorized by law to receive reports of child abuse or neglect. (45 CFR 164.512(b)(1)(ii))

Avoiding Record Keeping Errors (HIPAA)

Medical Error: Failure to keep accurate records. Non-compliance with HIPAA
HIPAA requires that records on patients be kept by all therapists to protect both the patient and the therapist. All therapists who use electronic transmission of files must be HIPAA compliant. At some point it is expected that all therapists will be required to keep HIPAA notes.

The records should include:
Identifying Information: Name, Date of Birth, Social Security Number, Address
Type of service: individual, couple, family, group; theoretical orientation; stage of treatment
Dates of Service
Action Taken
Fee and Insurance Information

Informed Consent for Treatment

HIPAA allows therapists to keep private process notes which can be used to document thoughts, the therapy relationship, theoretical opinions and other matters which do not directly pertain to the treatment plan for the patient.
Patients, under HIPAA have a right to see their notes within 5 days and have access to a copy of their notes within 15 days. While the file is the property of the therapist, the information in it is the property of the patient. While a therapist can prevent a patient from seeing his or her notes due to danger to the patient, the patient can have a copy of the records sent to another psychologist who can then discuss the notes with the patient.

Length of time to maintain records

While it is suggested that psychologists should keep full records for 3 years and a summary for an additional 12 years, there is no legal standard. Be sure and check with your board before discarding records. This changed in January, 2007. Psychologists will be required to keep notes on their patients for 7 years after the conclusion of treatment. Thus far, the law does not address clinicians who have followed the previous law, or lack of it, and destroyed notes when treatment was concluded or a year or so afterward. The law will also require that a summary of the notes be kept up to 12 years. Because this is a new law, patients, therapists, or others may find it unreasonable to keep records on people for such a long time. However, it would certainly benefit insurance companies to know that someone who applies for individual health insurance had emotional problems up to 12 years ago and may enter into a costly course of treatment again.

To avoid medical errors understand how to use the Ethics Code in your practice.

Follow the rules and guidelines of the ethics committee for your practice. Make it a habit to check in on the APA web site and the Licensing Board Web site on a regular basis so you know when laws are changing. Unfortunately, some therapists were convicted of violating ethics of their profession when they were following what had been a typical pattern but was in the process of changing. When you are uncertain about the rules, ask. Get answers in writing if possible. Know the name of the person with whom you spoke regarding how to most appropriately do tasks or render treatment. Consult with other psychologists and inform them of the difficulties you face. Seek formal supervision. Seek legal consultation. Be wary of dual relationships. Be wary of any sort of variation in billing and collecting fees. Identify the symptoms and sources of burn-out and countertransference in yourself, and recognize similar symptoms in colleagues and supervisees and handle these properly.

Know and understand the meaning of laws pertaining to the welfare of your patients as well as the rights of patients.

The development of an ethical practice will help you to avoid some of the more important errors psychologists make. Regardless of how many times you read through the law, regardless of how many classes you take in ethics, regardless of how well you follow the rules of the profession, make no mistake, this is a path you will need to pursue consistently throughout your career. To be sued successfully for malpractice in a civil court, the patient must prove that you have breached the standard of care (Black, 1996). There are four parts which must be seen by the court to have been met for the malpractice suit to proceed.

(1) As a psychologist you have established an agreement between yourself and your patient that you will work together in a therapeutic relationship. The law does not define this in terms of the length of time you have seen the patient, whether or not the patient has paid you. It is entirely the responsibility of the court to determine whether you have established a Duty of Care with the patient.

(2) The work you have done with this patient will be compared to the Standard of Care. This is also defined by the court based on what the court finds is the typical level of proficiency which would be shown by a psychologist under similar circumstances. It may be defined or suggested by an ethics code, a state standard, or case law. There is no clearly defined standard of care since both you and the circumstances in which the act occurred are unique.

(3) The patient must show that there has been some Demonstrable Harm. Although some texts may imply that it is difficult to show demonstrable harm if it is psychological in nature since the patient began treatment presumably due to harmful or painful problems which they hoped to cure, again, it is entirely the duty of the court to determine if you caused harm and, if so, how much harm was caused. The amount of harm caused whether psychological, physical, or financial can only be remedied in a civil suit by money. The court also decides how much money should be given the patient (now plaintiff) for the harm you have caused.

(4)The patient must also prove the psychologist was directly responsible or the Proximate Cause for the harm which was done.  So, the patient must prove that the psychologist had an established relationship with the patient which would prove there was a duty to care, was working below the standard of care, which caused demonstrable harm to the patient which could only have been a direct result of the psychologist's actions.

Despite these levels of proof which sound difficult to attain, many psychologists are sued successfully or have out-of-court settlements against them each year. Following a successful suit or settlement, one should expect an investigator from the Board of Psychology to visit to determine whether or not the actions taken by the psychologist were egregious enough to sanction them by loss or suspension of their license, additional classes to educate the psychologist and attempt to prevent further problems, or other measures.

Important Things  you  can  do  to  Avoid  Medical Errors

First, it is important to take care of yourself. Psychologists who are having problems within their own families, use alcohol or drugs inappropriately, are having emotional problems, or simply need a vacation are the most likely people to make minor and major errors in their treatment of patients. This may occur from the distraction caused by the psychologist's own problems or from unconscious motives which are more likely to be enacted when one is not at one's best and inhibitions are lowered.

Second, stay in touch with changes in laws through professional organizations. Maintain your memberships and attend meetings on a regular basis. You are likely to find it is helpful to know someone you trust for a consultation if you do find yourself feeling that a patient may cause problems for you.

Third, look at your mail at a time when you can do some reading. Instead of stacking the journal you just got, scan through the articles and read the ones that interest you. You could try out some of the new techniques you read about and develop some skill with timing.

Forth, if you have a patient walk in who describes a history of lawsuits, suicide attempts, and has a gambling problem which might cost him/her more than one can afford and you feel the acid turn in your stomach and your headache begin, check on the patient's current level of suicide risk and then on your own level of expertise in managing difficult patients. Do not agree to see anyone who walks in the door. Make sure you have experience with the presenting problem, that you know people in the field who are experts to whom you can turn if serious problems begin to arise, and realize you are free to refer the patient to someone who may be better suited to treat him or her.

Fifth, do not take on more patients than you can reasonably manage. If you see a patient who is challenging for you for any reason, seek supervision or discuss the patient with colleagues, preferably in a formal manner. We all learn from the work we do with our patients and our toughest patients teach us the most, however, to provide the patient with the best care and to take care of yourself, seek information from those around you, especially experts. Reading journals and books on the topic is also very useful but it can lead to a false sense that you understand the problems you face with that particular patient when you only understand the issue in a broad sense. If you can, create a formal or informal group of colleagues who meet on a regular basis to discuss difficult patients as well as successes. While in some ways we compete for the same patient population, actually all clinicians are much better in some areas than others and it is incumbent on the practitioner to know where they stand in their ability to treat different sorts of difficult patients.

Most importantly, do your paperwork. It gives you time to reflect on what you are doing with the patient, whether they need to be referred for medication or other care you cannot provide. It is also illegal to fail to do it. Some people find they do this best when they complete a formal note in the 10 to 15 minutes between sessions while others find they need to lay out an hour several times weekly or a long afternoon to get it done. Do not underestimate how much time this takes. Completing HIPAA notes can become very quick and efficient if you have a system and do them regularly. On the other hand, trying to recreate the important points of a session from hastily sketched notes during an intense session at the end of the week is nearly impossible. You remember that it was an important session but often lose the crucial meaning which was derived from the work done that day. The main idea to remember is not to fail to do notes until you find yourself served a subpoena by a court or a disability claimant. The notes you create at those times are not beneficial to you or your patient because they lack credibility which comes from a case note which is written soon after the session. While all this seems self-evident, it is important to recognize that keeping notes for anything other than an aid to treatment in most cases was rare until HIPAA was imposed only a few years ago.

Last, know your limitations. Refer the patient when you have no experience or training in treating the presenting problem. Refer them if they scare you and you feel you will not be able to find a colleague or supervisor who can help you sort out whether or not you should give this patient a try and if you have someone to help if you find you have trouble. Refer the patient to a physician when the problem does not sound solely psychological. Always refer them if there is any question about whether medication would be helpful. If they refuse, note they refused and why. Refer the patient if they remind you of Mom, Dad, your children, or your spouse. Refer them immediately if you feel they sound just like you. If you smell alcohol and do not regularly treat people with substance abuse, refer them to someone who does. Refer patients who abuse other substances if that is not an area of expertise or one in which you want to develop expertise. Having a drug or alcohol problem may seem minor and secondary to the primary diagnosis but it is amazing how frequently a drug or alcohol problem becomes the main problem very quickly or the main reason why no progress is occurring in therapy.

The second part of this course requires the psychologist to read an article on root-cause analysis. The article is titled Root-Cause Analysis - For Beginners by James J. Rooney and Lee N. Vanden Heuvel. According to Rooney and Heuvel,  Root cause analysis helps identify what, how and why something happened, thus preventing recurrence. Root causes are underlying, are reasonably identifiable, can be controlled by management and allow for generation of recommendations. The process involves data collection, cause charting, root cause identification and recommendation generation and implementation. Exam questions will come from both sections of reading including the paper on root-cause analysis.

Root Cause Analysis Link




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