Medical Error Prevention 2023

Hey there, everybody. Well, it is that time again for those of us who are licensed in Florida to take medical error prevention. So I'd like to welcome you to Medical Error Prevention 2023. I'm your host, Dr. Donnelly Snipes. In this presentation, you're going to define the basic terms like sentinel events. We'll explore eight medical errors in behavioral health settings, identify 20 environmental hazards in behavioral health settings and prevention strategies, and then review 17 root causes of sentinel events as identified by Jaco and obviously what you can do about them. Now, I know that sounds a little bit dry, but I actually enjoyed putting this particular presentation together because I think there's a lot of really useful information for those of you who are in residential settings as well as for those of you who are in private practice. So let's start out with the terms just because we need to know them. A sentinel event is any unexpected occurrence involving the death or serious physical or psychological injury or risk thereof. So I think that's really important that we note that a sentinel event does not have to cause physical or psychological injury, but it has to have had a good probability of doing so. We just got lucky, if you will. An adverse event is a type of sentinel event, but you can have adverse events that are preventable versus not preventable. Problems caused by an error in treatment rather than the underlying medical condition are considered adverse events. Preventable adverse events are those events that occur when there's a failure to follow accepted practice at a system or individual level. So that's when we start getting into that whole malpractice area. And this is also when we start talking about root causes. And as I mentioned, we'll get there. That's the last part of the presentation. Preventable adverse events or sentinel events are defined as events that cause or could have caused an injury to a patient as a result of inaction or on the part of a health care provider. So did you fail to do something or as a result of an action or intervention in which the injury cannot reasonably be attributed to the patient's underlying medical condition? Did you do harm? Did you do something that traumatized the patient? Did you actually do something that caused harm to that patient? Now, in behavioral health care settings, a lot of times it's the the former rather than the latter. But we're going to take a look at the different things. So one of the first problems that we often see as a injury causing thing in behavioral health is mistaken patient identity. Now, this doesn't happen a lot, obviously this happens more in surgical settings, etc but in behavioral health settings, when you're doing etherapy, especially if you're not doing video, it can be easy for somebody to impersonate your client. So it's important that you have ways of verifying that the person you're talking to is actually the person you think you're talking to. And in residential settings, we have people in. In multiple people in a room in different residential settings. And it's important to make sure that you know which patient that you're actually going in to pull out before you start breaching confidentiality. Now, this is probably the least common medical error in behavioral health settings, but I wanted to get it out of the way. Misdiagnosis. Now, this is a biggie, in my personal opinion, and that can be caused by inadequate assessment. Somebody comes in and working in community behavioral health for many years, I can tell you that sometimes the sentiment from C Suite is that people will be diagnosed. And so it's important to, number one, make sure that the person actually does have the diagnosis and that you're giving them the right diagnosis and, and all the diagnoses. And what do I mean by that? I don't mean throw the entire DSM in their chart. What I mean is if they are presenting with depression, for example, it's important to also differentially diagnose and rule out or make referrals for things like thyroid conditions or medications that are causing symptoms, or sleep disorders like sleep apnea that can contribute to or cause many of the symptoms of a lot of the more common mood disorders. We're not physicians, but if we notice any of those things, it's imperative that we actually reach out and make that referral so the person can get a full multidisciplinary assessment. Thyroid issues often masquerade as mental health issues. Autoimmune issues, gonadal hormone imbalances, estrogen, testosterone can contribute to or masquerade as mood disorders. Nutritional imbalances can also cause problems in cognition, concentration, sleep, et cetera. So it is important that we recognize the person as a biopsychosocial human being. And we don't just say, okay, you're coming in. You say you're depressed. All right, I'm going to write down depression. Let's move on. We need to do that assessment to figure out what's causing these symptoms, which takes us to under or over treatment. Long wait lists can be a problem. And I put that in under treatment. Because if somebody comes in and they're in crisis, if they need treatment, or if they're motivated for treatment? And we say, all right, we got you on the list. We'll see you in six months. Then they may feel helpless and hopeless. And because we don't provide adequate, timely treatment, they may worsen or be injured by it. So it's important that we consider that if we have long wait lists, what can we do to mitigate that? And what resources are there for the client? So we don't just say good luck. See, in six months, are there intervention level groups that they can attend? Are there support groups? Are they, are there other professionals in the community we can make a referral to? What can we do? Because that person is there and they are asking for a lifeline. We need to make sure we provide that. Running late. This is another one that is very, very common. And a lot of times especially, well, not just especially in behavioral health, but when you run late, I'm not talking five, 10 minutes, I'm talking 30 minutes, an hour, where a person sitting in the waiting room past their appointment time, not only do they feel disrespected, but again, they may be in a state of crisis and they may be at the precipice of, you know, self harm, for example, and you don't care enough about them and their time and seeing them and their opinion to see them in a timely fashion. They may get up and walk out and there can be really negative repercussions. What do they do? And, and many of these may end up being contributing factors to what we're going to talk about later as preventable suicide. Involuntary commitment or lack thereof is another source of under treatment, if somebody is, or. And over treatment. We don't want to get too free and loose with involuntary commitment because we're afraid of being sued. You know, that's. That's true. And it's an ethical issue. An involuntary commitment is such a challenging decision to make for clinicians, which is why you need to have a clinical team that you can consult with. You need to have somewhere that you can get a second opinion. But it's important to know how to do involuntary commitment if it's necessary. Because if you don't, then, and the person engages in harm of self or other, then again you're liable and the patient has experienced significant negative consequences due to your inaction. And there are entire classes on handling suicidal ideation. So I'm not going to belabor that here, but it is a medical error. It is a medical error to fail to consider the dangerousness of somebody and then placement in an improper level of care is Another problem now that can be under treatment because there's no space in a higher level of care right now. And that is a systemic problem that we need to look at. It used to, oh, break my heart when I worked in. In residential community behavioral health, and people needed. Needed residential treatment, and we just didn't have the beds, and nobody else in the county had the beds. And so we were left to recommend intensive outpatient or outpatient treatment until a bed opened up. And that was inadequate, sorely inadequate, and most of those people actually dropped out. So in my mind, that is patient injury. In. In my mind, that is a medical error, whether it's preventable or not. You could argue, because we just didn't have the money, we didn't have the space, space to accommodate all of the people who needed residential at that point in time. But then there's also an improper level of care, putting somebody at a too high level of care because you need to fill a slot or because you know their insurance company will pay for a higher level of care. Totally unethical falls. Now, this is another thing. In behavioral health settings, obviously, if you're doing e therapy, this doesn't apply. But if you're doing outpatient therapy, if you're in private practice, let alone behavioral health, community behavioral health, people are going to be walking in your parking lot, people are going to be walking around in your facility, people are going to be walking into your office. And it's important to be aware of falls or, or the risk of falls for people and mitigate the problems that are caused if they do fall. People who are in residential facilities or detoxification facilities where they're detoxing from substances are going to be at a much greater risk of falls. And we need to be aware of this and arrange the environment accordingly. And we'll talk about that and all those environmental interventions. People who are on new medications may become dizzy, may have difficulty with balance, and that can include things even like SS our eyes. So we need to recognize that even though we're not prescribers, we need to be alert to the fact that if somebody just started a new medication, that they may be a little bit more unsteady on their feet. And we need to ensure that our environment is as safe as possible for them. Environmental hazards, floors. Any trip hazards like rugs that are on the floor or rugs that are. Or wires or anything that people can trip on and wetness. The gym I go to has beautiful floors, and they are the tile that looks like wood, but every time it Gets the least bit damp outside, you feel like you're on a freaking skating rink. And that's difficult for me in tennis shoes. I can only imagine if I was in heels or something else I'd probably wipe out. If there is wetness, I ideally have flooring that doesn't. Isn't quite that slick. But if there is wetness, making sure that you put up the slip and fall signs to alert people so they're more careful. And then again, this is only for residential but bunk beds, and many of you are not may not be familiar with using bunk beds in community behavioral health, but it happens. And this used to be something that stressed me out to no end in the facility that I worked at because we would have people ate to a room in bunk beds and these were people who were in early recovery. They're just coming out of detox so they're unsteady on their feet to begin with and we're asking them to climb up into a bunk bed and not fall when they're getting out. Not a good combination in my opinion. So that is one of those areas that if you are a supervisor in that area or even if you're a clinician in that area, you need to speak up. You need to say I'm going on record saying this is a problem waiting to happen. Communicable illnesses. This goes back to your bloodborne pathogens training. But we also have communicable illnesses like viruses and, and you know, to avoid the wrath of the algos, we'll just leave it at viruses. So it's important to have good hygiene procedures, make sure that your soap dispensers are filled and have policies for social distancing, for masks for when to stay home, maybe even have options for telehealth if somebody needs treatment, needs to be there, but they're sick. That way they don't bring those bugabuggas into your facility. You also need to have good procedures for disinfection and this is true for private practice as well as, you know, group or, or community behavioral health. Assaults are also something that we need to consider and it can be a patient on patient assault in the facility. It, it can be an assault by a stranger in the parking lot. It can be unfortunately an assault by a staff member on a client. Any interaction that results in a, an assault can be a potential in problem, can be a potential medical error and self injury assault by the patient on themselves can also qualifies as a medical error. If we didn't do everything we could to prevent it. And even if we did, it's still an adverse event. But you know, as I, as I mentioned earlier, not all adverse events are 100% preventable. Domestic violence is another area for assault. And this applies not only to brick and mortar counseling, but also on etherapy. People who are using technology in order to receive services who also have a co occurring issue of domestic violence, they're, they're a victim need to be extremely aware of computer logs of how to cover their tracks, of how to stay safe. Because there are so many different key loggers and trackers and everything else that the perpetrator can put on the computer or on the phones. They can put trackers on the phone so they know where the person is going, if they're going to your office. There are a lot of things that need to be considered if you are working with somebody who is experiencing or has survived and gotten out of a domestically violent situation. Your organization, again even if you are, your organization needs to have a very clear policy for how you handle that and how you help people who are experiencing or who have survived domestic violence stay safe. Preventable suicide and it's important to recognize that suicide of any patient receiving care, treatment and services in a staffed around the clock care setting or within 72 hours of discharge, including from a hospital emergency department, is considered a sentinel event. But that's not the only sentinel event. That's what JCO defines. But if you are in private practice, you're an outpatient, and you have a client who is decompensating and you fail to take action, that's a preventable suicide. It's vitally important that you regularly assess for substance use. We know that substances are often involved in suicide attempts or self injury. It's important that you do a mental status exam, at least a mini mental status exam in my opinion. At every single visit, are they oriented? Do they have thoughts of suicide or homicide? What's their attitude like? Do they have future plans? You know, all of those things. Just get your finger on the pulse if you will, and document it. If it doesn't go into the notes, it didn't happen and it's important to document it. Lack of adequate procedures or training on suicide assessment, prevention and intervention also contributes to what Jaco refers to as preventable suicide. Everybody needs to have training on it. They need to not be afraid of the word suicide. They need to know what their options are and they need to have actually practiced engaging with somebody who is in active crisis so they don't feel intimidated about how to handle the situation so they can actually present a presence of calm and, and calmness and strength when the person is feeling hopeless, helpless and out of control. And lack of follow up is another area that is considered a medical error. If a person just doesn't show up for treatment, you need to follow up. You don't know, maybe they decided not to come because their depression had gotten so bad they had attempted suicide. You need to follow up. If they don't come, maybe it's because their depression has gotten so bad that they are contemplating suicide. And if you would have followed up, then you could have intervened. Do not abandon your clients. Do not fail to follow up and say, well, it's on them, they're grown ups. No, if a person does not come, we are ethically obligated to follow up. Restraint Related deaths Now, most agencies do not use physical restraints anymore, with the exception of crisis stabilization units. And most people in private practice wouldn't use these. However, restraint related death is an issue that we need to consider, especially if you work in a place where laying hands on patients is considered an option. Al although a last resort. In one study they found that physical what, what I'll call mechanical restraints like straps, the immediate cause of death was strangulation in 11 cases, chest compression in 8 cases, or dangling in the head down position 3 cases. In 19 of the 22 patients, restraints were incorrectly fastened or improvised. Non standard restraint like a belt for example, were used. Not okay. And obviously in all of these situations the person wasn't being supervised. If they were, then the supervisor would have been able to identify the physical distress. And then we also need to consider improper restraint by an individual or individuals. And this is something that always caused me consternation when I was in Community Behavioral Health because it was an option of last resort, if you will. And just like with in, in other settings like law enforcement, we when you are physically restraining someone who is agitated, who is fighting, especially if you're not well trained, you can very easily injure or even cause them death. So it is something that your organization needs to seriously consider. And, and again, I could do an entire presentation on on that. But if your organization allows laying of hands on clients in any circumstance, you need to consider the pros and cons. So let's talk about environmental hazards. And I know I seem way too happy about that, but this is one of those areas that I don't think we cover in medical errors enough. And it's one of those things that applies to every clinician who sees clients in an Office people who are seeing clients with behavioral health issues need to recognize that there is always a risk of, or can be a risk of suicide, of self injury or of just falls. And so we need, we need to be aware of this and then we need to figure out how can we mitigate the risk. There's a great publication that was actually put out by the VA and there's a lot of things in there that may not apply to you because the VA has lots of special units and everything. But we're going to cover the ones that I think do apply in just about every behavioral health setting. So trash cans in bathrooms and unobserved rooms must be incapable of supporting patient weight. We don't want patients standing on top of trash cans in order to engage in self injury type behaviors. Likewise, we don't want people standing on top of trash cans and pretending, you know, kids can do it sometimes because they're, they're playing around, but then they can fall down and hurt themselves. So we don't want trash cans that can support people's weight. No furniture tall enough to reach architectural beams or pipes. Some places don't have drop ceilings, they have exposed pipes. Other places have exposed architectural beams in because of the way it's designed that can be used as a mount for, for ligature. And it's important to recognize that and make sure that that is not. There's nothing tall enough where a person could easily throw a sheet or a ligature over a beam or pipe that would support their weight. Beds, desks, nightstands and tables should be bolted to the floor to prevent moving. Now moving beds, moving any of these things, sometimes they're heavy. So we don't want people moving them and injuring themselves in the process of moving them. Okay so that's one area. We also don't want people moving them to use them as a platform to injure themselves or use them to block doors so staff is unable to access them while they are injuring themselves. So it's important that we think, you know, how can this be used and how can we prevent it from being blocking the door? Clocks, signage, mirrors, tables and artwork, all of these things may have glass faces on them. And it's important to, you know, pay attention to that. They, they also may sharp edges, they should have no sharp corners and should, if there is glass in them, should have non breakable glass. You don't want people being able to break the glass and use it to assault themselves or someone else in terms of artwork, vinyl stick ons and that's very common. To see anymore. You see lettering and messages on, on walls. They've come a long way to make vinyl. Vinyl stick ons look very nice, if you will. You can also get pictures that are printed on plastic, I guess, and you can mount them to the wall with silicone. Again, you want to make sure those pictures have rounded edges. You don't want the corners of those things. You don't want it to be able to be ripped off and somebody use the corner as a weapon. Frameless artwork can be printed on acrylic with rounded edges. You can also use tapestries and you can see in a little bit. In my office, I used sofa throws. They're like 45 by 60. And they can be hung on the wall and they can be very, very pretty to use. Instead of using hard, hard art, you can also use traditional art with traditional frames if it's within the direct line of sight from staff. So if it has glass or it has sharp corners to it, just make sure that staff is able to see it. So people are less inclined to monkey with it. Housekeeping carts are lockable. So all of those chemicals and anything that might be sharp or used as a weapon can be locked. And they have rounded corners. So if somebody falls next to a housekeeping cart, they don't fall and conk their head and end up cutting themselves because the corner was corner was sharp. And those carts should always be attended. Locks can be jimmied. Housekeeping carts can po compose a significant hazard in many situations. A lot of them have plastic bags on them, so it's important that anything on the cart stays locked and a lot. And the cart is also supervised. If you have a psychiatric wing or a CSU in which you're treating people who are acutely suicidal or homicidal, Sally ports are helpful. And that's when you have a vestibule that people go in before they go into the main part. And that can help prevent people from leaving, from escaping. And it can also help control individuals if they are particularly combative initially. That way they are not going in and disrupting the rest of the facility. If you run an outpatient program, especially if it's group outpatient, you may consider having lockers for outpatient belongings. That way nobody is bringing in weapons, nobody's bringing in drugs, nobody's bringing in contraband, and ideally, nobody's bringing in digital devices that can be used to record what's going on and then breach confidentiality. So those lockers for outpatient belongings can be super helpful. And it's a much more in My opinion, humane is not the word I'm looking for, but it's a much better solution than saying, okay, all your purses have to be completely see through. That is a violation of privacy in my opinion. But outdoor lighting and working cameras are important for anything that is on your property. That way you are able to see what's going on. And I say working cameras. You don't want to just have cameras there for camera's sake. To act as a deterrent, the cameras need to be working. Ideally, they're monitored, but not Everybody can afford to 247 monitor what's going on. Ideally, the cameras are. Camera monitors are set up by the reception desk. That way the receptionist can keep an eye on what's going on. The outdoor lighting is adequate and maintained so people aren't walking out in the dark. And there's no, you know, we want to be safe, minimize dangers to people because even though they're outside, they are still on your property. They are still expecting to have the same safety they would have in your lobby. For example, alarms on exterior doors and windows. Now this mainly refers to alarms on doors and windows that aren't supposed to be being used. If you start putting a lot of alarms and locks and keypads on front entry doors, it can make a lot of people feel like they are entering a prison. It can make people feel unsafe because they feel like, well, if I go in there, maybe I can't get back out. So you want to consider the degree of alarms and stuff, but you also do want to make sure that windows in bedrooms, for example, and windows and offices do have alarms on them that, you know, if it's in an office, the person who has the office can turn it off. But that way if you go out to get a cup of coffee or something and the client is in there, you know, if they try to leave through the window, it's expensive, but it in your facility, if you can afford it, tempered glass windows break apart into very small but dull glass pieces. So if somebody does break a window trying to escape, or they break a window because they want to get a weapon, it's not going to work. It's not going to help them. Tempered glass is very hard to break and when it does break, the pieces are dull. They can't be used for self injury. Mattresses for inpatient units require additional consideration. Zippers, cording and non breathable materials are all things that must be eliminated from the mattresses provided in a residential behavioral health setting. And it's important that you don't just think, oh, that's only for psych hospitals. No, people who are in residential treatment can become acutely suicidal very quickly. So whether it is a mental health unit or a substance abuse unit, if it's an inpatient unit, you need to be cognizant of these things and eliminate as many hazards as possible. Apparently, and I learned this doing this presentation, they have something that's called psychiatric safe bed linens. And these bed linens are typically thicker and tear resistant. Now you might think, well, don't you want them to tear? Well, no, because if they're too thick to be able to be used, to be able to be wrapped and tied and things, people may try to rip them in order to make them thinner so they're more workable. So you don't want them to be able to be torn and you want them to be thick so they can't be easily manipulated and into something that could be used as a ligature. So I thought that was really interesting. Closet and wardrobe hanging bars should not be able to support human weight. And depending on where you are, you know, you may be able to have. I like the rolling wardrobes and I have those in my garage right now. And I can tell you not only will they not support human weight, sometimes they fall apart when I'm moving them. But that's a whole other issue. If you get the good ones, people can push them in and out of their closet and have their stuff on it, but it is not a structure that is going to be able to be used in a way that is self injurious. Rolling wardrobes, you know, and whether they can be put into a closet or not, that would be my preference for a residential sort of facility. Same thing if you are in private practice and you have a coat closet that is not supervised, maybe you don't have a receptionist, you just have a waiting area and you know it's you and you alone. Well, you don't want people being able to harm themselves while they're sitting in your waiting room. Cordless window shades are important if it's, if there's a shower in your facility, the curtain rods should hold very little weight. Most shower curtains are going to tear pretty easily, but the shower curtain rod should be, you know, not overly substantial because most shower curtains aren't very heavy sloped or recessed. Paper towel dispensers in the bathrooms are also important because you don't want somebody to be able to tie something around it and use it as a support and soap in auto dispensers is also recommended. That way, you know, we know that there's soap available. It's much more hygienic. There's a lot of reasons you don't want to have like bar soap sitting out. Now, these last three were not addressed and, but I think they do bear thinking about in your facility, hand sanitizer. Now, people went absolutely bonkers with hand sanitizer over the past few years and I understand why. But it's also important to recognize that in, especially in, in psychiatric units and substance abuse units, it's not uncommon for people to actually try to drink hand sanitizer in order to get high. You know, sorry, that's just the way it is. So it's important to weigh the costs and benefits and figure out how you're going to keep people safe. I don't know how my old facility handled that during the pandemic, but I know when I was there, they ended up having to remove the hand sanitizers because it was causing it. It was happening too frequently that somebody would ingest hand sanitizer because of its chemical composition. Hot coffee is another one. Hot coffee can be spilled on people, it can be thrown on people, it can burn their mouth, it can burn their body. Is this something that you have and how can you handle it? Now some people have said, well, we go to single serving, like Keurig type machines. Okay, well that's great. They don't have a whole pot of coffee to throw on them on, on themselves or someone else, but they still have one cup. The other problem with coffee pots, the old fashioned kind, most of them are not tempered glass and most of them are glass, so they can be broken to make a weapon. And eating utensils, most places use plastic eating utensils. That would take a lot of work in order to make them harmful to someone. So in an outpatient facility, probably not that big of an issue. Especially if everything you're using is, you know, the cheapy plastic stuff. If you're using metal utensils that could be harmful to someone, or if you're in a residential facility where people can take utensils out of the cafeteria and potentially make a shiv, you know, let's just call it what it is. It's important to be aware, it's important to figure out how can you prevent this from happening in the most respectful way possible. You don't want to be doing pat downs of everybody every time they leave the cafeteria. That's, that's not respectful. And yeah, enough said. And finally, root causes Jaco identified multiple root causes that we're going to go through here. And there were others that were identified that just really didn't apply to Behavioral health, but these do. And I mentioned earlier inadequate methods of identification not only of patients, but also of staff. You need to make sure that staff has adequate identification before they interface with patients, before they look at records. Before, you know, you need to make sure. And in private practice, that's not that big of a deal because you know who you are, you know the receptionist. You got it. But in Community Behavioral health, you need to know that whoever's coming in and going into your medical records room, for example, actually belongs there. So badges with pictures are important. And a lot of places have the digital swipe badges now, too, but anybody can pick up a digital swipe badge. So it's ideal to also have pictures. If your facility hands out medication, it's also important that the patients provide picture identification. And we switched to that as I was leaving Community Behavioral Health because we did have a nurse on staff who facilitated medication every single night. And it was important that we make sure that the person getting the meds got the meds they were supposed to get. Incomplete assessment on admission. I talked about that already. But it's really important for you to think about, am I assessing everything and am I allowing enough time to do a thorough assessment, or is this just a autopilot check the block thing so we can start, you know, sitting down and chatting? It is important. Even in private practice, it's important to do a thing, thorough assessment of the person and not just say, okay, you've got depression. Let's. Let's talk about that. No assessment. And that's how you rule in or rule out or make referrals to identify other causative factors that may be contributing to the person's distress. Conducting assessment and treatment in an automatic fashion. If you have a plug and chug treatment program, you know that is potentially a root cause for problems because everybody's different. So you can't say that all people with addictions need to go through this particular course of treatment, or all people with depression need to take this medication and do this and do that and do the other. Yes, there are foundational skills and tools that can benefit people with various conditions and disorders, but they're not necessarily all appropriate for every single person. So it's important to individualize assessment and treatment, seek advice and communicate with colleagues and your multidisciplinary team. I know I've talked about this multiple times already, but people are biopsychosocial creatures. And most of the time, in my experience, people with mood disorders or psychiatric issues also have some psychosocial, environmental and physiological issues that are contributing to their presenting issue. So we need to consult with a multidisciplinary team. I strongly, strongly advise people to make sure that they're, they have a process for communicating with the person's physician. Yeah, we're supposed to do that for a reason. And for communicating with or making referrals to a sleep physician and a nutritionist or dietitian at the very least. Now, not everybody's going to need those referrals, but it's better to have them available so when you need them, you can make the referral than to wait till the last minute. You don't want to misapply your expertise or what my old supervisor used to call leave your lane. We are clinicians. We were trained to handle mental health issues. We are not going to diagnose, you know, the causes of a lot of sleep problems. Even though sleep disorders are in the DSM 5, most of us don't do sleep studies. We don't interpret sleep studies, we don't prescribe medications. That is in the physicians ballpark. Most states have laws that say if you are not a registered dietitian, you cannot prescribe nutritional interventions. So yes, you can educate people about nutrition, but in terms of creating menus or prescribing nutritional interventions, that needs to be left to the experts. So don't leave your lane. Don't do hypnosis if you're not certified as a in hypnosis. Don't treat young children if you haven't been trained in treating young children, yes, legally you can, but ethically not so much. Children are not little adults. You cannot necessarily expect to be able to effectively work with a child if you haven't had special training. Make sure that you have a treatment and a safety plan. And I see this so frequently in, especially an outpatient in private practice where people skip over that. A lot of times they skip over the whole assessment piece too. But even if there is an assessment piece, there isn't much in the way of a treatment plan, goals or a safety plan. And those are really critical pieces to create a solid foundation and provide direction for treatment. If those don't exist, it can be a root cause for problems because you may end up causing the person more harm by not having fully assessed what's going on or by keeping them in treatment for too long or discharging them too quickly because hey, their depression seems to be better. Oops, I forgot to treat the substance abuse or I expected somebody else was going to do that. That's not cool. If they've got co occurring issues, even if you're not treating them, it needs to be in the treatment plan that they are being treated by. XYZ practitioner. It's important to consider the most obvious diagnosis and do an effective differential diagnosis. Just because somebody comes in and they say, hey, I'm depressed, as I've already mentioned, that can be caused by anemia, vitamin D deficiency, hypothyroid, low estrogen or testosterone, cognitive difficulties, sleep disorders. Those symptoms can be caused by a lot of things. So we need to consider those things. But we also need to recognize that sometimes it is situational depression. They just got divorced and they're depressed. Okay, you know, you know, it's an adjustment disorder. As the DSM would say. Failing to obtain consent. This is more medical than mental health. Ethically, failing to obtain informed consent is a huge ethical violation. And in some states like Florida, failing to obtain, obtain informed consent is actually legally a problem. You need to obtain informed consent. And I refer you to either the presentation I did on informed consent or to the Americans Counseling Association Code of Ethics, their section on informed consent. Because there's something like 21 pieces of information that need to be an informed consent. It's not just a I agree and consent to counseling. Failing to provide education to patients is also another root cause. And this one in particular occurred to me or with one of my patients. I was talking to her one day and I knew that she was on psychotropic medications and she told me that she had been drinking a fifth of whiskey every night in order to pass out. And, and it was important that I educate her at that point about the dangers of mixing alcohol with her medications. There's also people who take things like Sami or CBD or valerian root. All three of those will interact with psychotropic medications. We are not going to tell them to adjust their medication at all. But it's important that we educate them about the dangers and, and communicate that information. Hopefully we've already gotten a release. Communicate that information to the treating physician. Ideally the person will tell them themselves. It's, it's better if it comes from the client themselves than you tattling on them. So we do want to advocate for that. But it is important that we get verification that they have communicated with their physician deficiencies in education, training, orientation and experience. Well, you don't come out of grad school with a whole bunch of experience, which is why it's important to have a team that you can confide in that you can rely on for consultation. But it's also important that you get appropriate education. And if you don't feel comfortable handling something, maybe you've never been trained in addictions treatment and you're suddenly assigned to an addictions unit. All right, well, that's a deficiency in education. Not your fault, but it needs to be addressed. You need to know that you've got training that you can access and mentors that can help you in the process. If you're working with somebody, for example, who LGBTQ and the coming out process, that is not something that I have ever worked with in practice. Therefore, if I had a patient who was going through that process and that was a treatment issue that we were discussing, I would need to seek out consultation, I would need to seek out education to make sure that I do no harm. Inadequate policies to guide the workers, you know, how do you handle certain situations? And if there are no policies, then it can sometimes get a little murky in terms of preventing harm. So there need to be clear standard operating procedures. And for a lot of places, that's, that's why the procedure manual gets to be printed, of course, gets to be about this thick. Because as things come up, new standard operating procedures are added. It's important that people are aware of that. But it's also important to know that if you've got a 1500 page manual, people aren't going to remember everything. So there needs to be regular audits of the system to identify frequent problems, to identify areas that could be a problem and intervene in those areas early before they do become a problem. A lack of solid leadership, which leads to not knowing who to report problems to or a failure to disclose the issues. If there's no solid leadership, it's like, you know, don't tell me, I don't want to know. Okay, that's not helpful. We need to get it out. We also need to have a policy that encourages reporting of adverse events and sentinel events instead of punishing. If somebody is afraid that if they report a problem they're going to get fired, then they're less likely to. Less likely to report it. Likewise, if you have a disjointed system with no problem solving ability, then when there is a problem, it probably just floats out there and never, never land and gets passed around from person to person and everybody goes, I don't know what to do with it. That's not okay. Somebody the buck has to Stop somewhere. And when there's a problem, there needs to be a paper trail and there needs to be a way to solve the problem, ideally with a committee. I know I used to hate sitting on committees, but a committee is important because C suite executives can tell you in theory how things should be handled or how things were handled back when they were line staffed 30 years ago. But that may not be applicable now. So we need to have line staff. We need to have supervisors, ideally in, in a lot of cases. We also need to have representation of the person served so we can figure out how do we solve this, how do we make this a safer environment physically and emotionally for you? Inadequate staffing and poor supervision. I'll just lump them together. There aren't enough bodies around to see all the people who need to be seen. And there's a high turnover rate and a high burnout rate. And a lot of people who are supervisors were never trained to be supervisors. And you know, you may be thinking, well, I'm a clinical supervisor, I took the 16 hour training, blah, blah, blah, yeah, that's great, I'm glad you had that. And you also need other training on administrative supervision and periodic retraining on clinical supervision. Things change and we can all benefit from refreshers. Supervisors are often spread too thin as well. So when line staff need supervision, they may not be able to count on their supervisor actually being there. So it's important that supervisors are equipped to supervise and available to supervise and that there is adequate staffing for the caseloads that, that exist. And there has to be somebody prepared to accept blame and change the system. Sometimes that is a really outspoken supervisor or line staff person, other times that C suite executives or your quality improvement director. But there has to be somebody that receives the reports of problems and is prepared to say, okay, what, where did this go wrong and what do we need to do to change it? And who will recruit the appropriate people when there is a problem for the root cause analysis meeting. And I used to find those fascinating. Let's, let's, I'm sorry, they just were. Because it was an opportunity for us to learn from our mistakes. And the way my facility did it was very non judgmental, non punitive. And we sat there and we said, okay, let's talk about all the things that could have contributed to this problem and see if we can devise a better way. You know, it was, it was a very productive, proactive process. Ultimately, medical errors are things that cause physical or psychological harm to our clients. And there are a variety of them. Yes. We don't prescribe medication, so that's not an issue we're going to deal with. We don't operate on people, so those issues we aren't going to deal with. So a lot of the stuff, when you Google medical error prevention doesn't apply. Which is why I think it's important to recognize that medical errors can come in the form of having an unsafe environment or. Or failure to provide adequate quality care.