 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation, Medical Error Prevention in a Comprehensive Integrated Systems of Care. In this presentation, we're going to identify medical errors common in a comprehensive integrated system of care, including pain management, because a lot of us deal with patients who are seeing multiple, a lot of us are dealing with patients that are seeing multiple physicians. So it's going to be important to understand how to interact within a comprehensive system of care. We'll discuss how pain influences the comprehensive treatment process because that's really going to be kind of critical. And we'll identify some of the causes of medical errors on our part. That is from a clinicians, a mental health clinicians standpoint. What things can we do that might be a problem or what things do we maybe miss that we need to be doing. We'll describe the effects of medical errors on the patient and family and identify common documentation and communication errors in multi-disciplinary teams. We're also going to define what a medical error is because this is a medical errors prevention course and identify the factors in a credible root cause analysis. Finally, we'll describe other interventions designed to prevent harm and protect patient safety commonly utilized by therapists. One of the reasons we do this class is because in the state of Florida, almost every licensee that I know of from nurses to clinicians, mental health clinicians to social workers, we're all required to have medical error prevention. And I think some other states are kind of jumping on that bandwagon. So what is a medical error? And we're going to take this definition from the National Institute of Medicine. Medical errors can include diagnostic errors, which is errors or delay in diagnosis. It's important to understand that we need to pay attention to what's going on with our patients and make timely referrals for them. A failure to use indicated tests. Now, for a lot of us in mental health, that's really not as crucial. When we talk about an indicated test, though, one thing I will turn your attention to is making sure that when you do see your client every single time, you at least do a mini mental status exam. And it doesn't have to be super interactive. You can even do this in group. I mean, if the person is oriented to person place and time doesn't have suicidal homicidal ideation that they're espousing. These are all things that you can pretty well glean from a group session as well as an individual session. But we want to make sure that we put in the notes how that person was doing on that particular day. Use of outdated therapy techniques and in mental health counseling, you know, things aren't necessarily ever totally outdated. There are things that you want to consider in terms of what's the best practice for this particular diagnosis at this point in time, whether we're looking at dbt or CBT or humanistic or psychoanalysis EMDR. There are a lot of different approaches. Some have or some will be more prevalent for treating certain diagnoses than others and part of that's going to depend on your training to and failure to act on the results of monitoring or testing. So if you're doing your mini mental status, even in group and you notice that one of your group members is not having a good day seems to be confused. Maybe a little bit agitated and you don't act on that as we talked about last week. That could be a sign of medication problems that could be a sign of serotonin syndrome that could be a sign of intoxication impending, you know, psychosis or dementia there are a lot of things that could be coming up if your client has a significant change in status. So you don't want to necessarily just say, well, Jim Bob's having a bad day. We're just going to, you know, hope he's doing better tomorrow. You want to pull him aside and go tell me what's going on. Another medical error is in the treatment realm, if you will, the error in the performance of procedures or tests. And one of these things and I will harp on it is using tests that are not normed for your population. Don't use a test that was normed on college age, white males, if you're dealing with an African American adolescent, you know, and when I say adolescent, I'm thinking under 18, not your older adolescents. It's not normed on that population, you want to make sure that the test you're using is normed and applicable to the population that you're applying it to. Otherwise, you might come up with a lot of false diagnoses or inaccurate indicators. You want to avoid avoidable delays in treatment or responding to abnormal tests. So when somebody comes in for an assessment and you notice that they're they're struggling, they're having a difficult time staying clean and sober or they're having a difficult time managing their depressive symptoms. It doesn't give them that warm fuzzy feeling if you go, okay, thanks for coming in for your assessment. You can start treatment three weeks from Tuesday. Yeah, no, we missed the boat here. So if we're, you know, getting them into treatment we do the assessment we identified that there's a problem. We want to have some sort of recommendation for them. If you're working in community mental health, I know it's not always a panacea, but you want to have some other alternatives are their support groups the person can go to can they start seeing an individual therapist while they're waiting to get into IOP. Are there other alternatives so the person who has presented who theoretically is motivated and in need right now can start accessing services. If they're being taken away, not only do they feel like a number that you don't care about them. Often, but it also risks them decompensating even further so we want to make sure that we have some kind of referrals to bridge the gap if there's going to be a delay between the assessment and when they can actually start treatment. And using inappropriate or contra indicated care, the type of care. You know, you're not going to necessarily use psychodrama with every patient, you're not going to necessarily use humanistic therapy with every particular client. We want to know from a individual standpoint, you know from that person's standpoint as an individual from a cultural standpoint from a diagnostic standpoint, what is the most appropriate type of care. And if the best practices indicate that some sort of medication might be helpful in what with dealing with this diagnosis, we might want to make the referral or at least offer the referral to the patient to go see the psychiatrist or the pain management physician or whomever it is. So we want to make sure that not only are we providing the right type of treatment, but if they're presenting with a bio psychosocial issue which guess what most of them are that we make sure we make the appropriate referrals to other providers in the multi disciplinary team in order to cover all of our bases. The intensity of treatment. We went through that when we talked about the ASAM and the locusts and all those other things, but the intensity of treatment is really important. Not everybody needs to be in intensive outpatient or PHP or residential. But you also don't want to just automatically stick everybody in individual and if they fail there then bump them up so it's important to use patient placement criteria in order to determine adequate or appropriate intensity. The breadth and diversity of the care and and that's kind of what I was talking about earlier. If it is indicated in the best practices that this is something that should be treated by a multi disciplinary team. We want to make sure we make those referrals. If the patient chooses not to follow up on them chooses not to go to their primary care and have a physical. There's going to be a policy decision with your agency about how to handle that but it's important that we help them understand that there could be a lot of causes for fatigue and apathy and confusion and all those symptoms that are depressive symptoms if you will. And we want to rule out some of them. And the duration and this is another soapbox that I am. I typically get on most patients will reach a maximum gain at that level of care in anywhere from two to three months, unless there's something severe and persistent going on. When I see clinicians who've been seeing the same client every single week for three, four, five, 10 years. That makes my spidey senses go off, because in a way that clinician may be establishing a dependency with that client saying you need to see me every week because you can't handle life on life's terms. And I've seen it before and I've seen it more often when I'm auditing records and stuff, the clients that tend to stay on the longest are the clients that tend to show for every session and maintain a balance of zero. So these are your ideal clients. That's we don't keep people for that reason and I think most of us know that, but a medical error is continuing to provide treatment when a client has reached maximal gains at that level of care. Medical errors in counseling. We often work with multi disciplinary teams and each team has their own language has their own their own stuff that's like common sense to them. And we can get kind of lost in the confusion. So if you're dealing with a multi disciplinary team, which is awesome because I think they are most beneficial. Most of the time, it's important to stop and clarify and ask questions. And if they ask questions of you to respond, you know, as well as you can without going, how can you not know this? Because we all are specialists in our own particular areas. So it's important to be able to talk with the pain management specialist openly about the medications that he or she may have your patient on. And, you know, talk about different concerns in terms of side effects treatment compliance, etc. So we want to make sure that there's an open line of communication that starts with releases of information. Ideally, now there are some workarounds in HIPAA when it comes to providing continuity of care. I always suggest getting a release of information for each care provider. It's a much safer way to go. So we can make sure that we're all on the same page. Prevention. Failure to consider multiple causes of symptoms is another thing that we want to look at in terms of prevention of medical errors. As I said, there are a lot of different things that can cause depression. Hypothyroid and depression look very, very similar. Yes, the mood issues are present because when the thyroid is not working, you don't have much get up and go. Inbalances in other hormones, especially your sex hormones, testosterone, estrogen, males and females. That can also cause symptoms of depression. So we want to make sure ideally that we rule out the biological causes of the symptoms. And yes, there's probably some thinking issues that are going along with it, but patients will have much better success if we can identify the root issue and help them start dealing with that. And then some of the cognitive stuff that may have developed in response to the feelings of depression caused by the root issue we can deal with. And they may have had some cognitive stuff going on first too, and we can deal with that. But if we don't treat whatever's causing the neurochemical imbalance, we're going to be kind of behind the eight ball when we're helping clients feel better perpetually. We want to ensure that we provide preventative treatment. And yeah, we're not going to call people in and go, Hey, you don't have a problem right now. Come pay me my hourly rate so I can provide you prevention services. People aren't going to do that. But we can have prevention information such as information about serotonin syndrome in our waiting room so people can read about it. We can have little handouts that are in our waiting room that help people learn more about dbt skills, you know the improve or accept acronyms as ways to deal with the stress and feel better. We can have videos going because I mean you can even have YouTube video playlist going on a loop in your office in your waiting room to help people learn particular skills or learn about issues that they might be experiencing. So there are a lot of different ways we can provide preventative treatment. We can also inform clients. If we hear something in session that makes us think you know this is kind of dangerous here. Medication interaction or if we hear that they're engaging in certain behaviors that might be problematic. We can educate and they can make the decision from there. We also need to monitor and follow up on treatment from a prevention standpoint to make sure they don't decompensate. So, if we make a referral to a physician or to a pain management doc or all of the above, we want to follow up on those referrals if we believe that that is significantly impacting whatever reason they're seeing us. But we also want to monitor and follow up on our treatment and make sure that we're checking in with them periodically to see if any other symptoms are coming up. If anything else is going on, if things are improving, we want to be able to monitor, which is why we typically do clinical reassessments every 30 days. We also need to communicate with other team members. If we make the referral to the physician, we need to communicate and go, hey, what did you find? Now they may send back a report with the client and that's dandy. But we also need to make sure that we have open lines of communication. If we find out that, for example, a client is on antidepressants and drinking copious amounts of alcohol, not an alcoholic, just drinking a lot, not supposed to mix the two, serotonin syndrome warning, among other things. We want to advocate or encourage the client to talk with their physician, preferably make that call and talk to the nurse or something while they're in our office, or call and have a meeting with the doctor, and then we can follow up on that. But we want to make sure that everybody on the team knows what we're doing and if there's a problem, we get it communicated to the right people. We don't often have equipment failure, so that's not a huge deal unless you're doing tele-mental health. If you're doing tele-mental health, you need to have a backup system in case your internet or power goes out. And other systems, if your EHR goes complete, what are you going to do if the client requests records? What are you going to do if another provider on the treatment team needs access to those records? Ideally, you have a backup and your IT department can get those handled, but that is a medical error. If you can't provide treatment or provide information to other members of the team, it's going to impair continuity of care. Documentation and communication errors. We all have our own shorthand. When I was at the community mental health facility that I worked at, there were certain shorthand things that we were allowed to use. Everything else? No, we had to write it out. And that made sense because the things we were allowed to use like DX for diagnosis. Doctors get that, physical therapists get that. That was understandable to everybody on the multidisciplinary teams. We didn't want to use certain other shorthand things that we would get lazy and try to use. We want to improve or ensure that there's communication between teams, providing quality documentation in a timely fashion that you don't have to have a dissertation. I used to have clinicians who would write beautiful case notes and progress notes and comprehensive assessments. They were wonderful, but they were dissertations. And at a certain point, I had to say, you know what, these are gorgeous. Love seeing them. However, in order for you to be able to get your documentation in in a timely fashion and not be here until eight o'clock every night, let's talk about, you know, what has to be in here and what doesn't. We want to have good quality that communicates the who, what, when, where, why, and progress on each treatment goal in our progress notes. So we want to make sure it's comprehensive, but we don't need to have two pages every time a client comes in. There needs to be a single point of contact in a multidisciplinary team. So if something starts to go awry with a client, we know who to contact that will make sure that everybody on the team gets the information. There are five people on the team. We don't want four of those people calling the doctor and four of those people calling the clinician to tell them the same thing. So when something goes wonky, who do we tell? HIPAA violations. Like I said, there are some loopholes for continuity of care, but it's really better to make sure that you have a signed release of information for each provider on the client's care team. That also puts it out there for the client for informed consent about who you're going to talk to about what. We also don't want to make assumptions without clarification or confirmation about reasons for medications the patient is taking. I've had clients that have been prescribed saraquel before. Now, saraquel is a pretty intense atypical antipsychotic, but a lot of the physicians that I used to work with would prescribe it for sleep. So, you know, you could get two very different pictures of a client when you looked at when if you just assumed that saraquel. Okay, we must be dealing with some sort of psychosis. No, they were just having a hard time sleeping. We also don't want to assume the causes of pain or distress. We want to ask the client what is causing this situation that's going on for you right now. Because what's devastating to me may not be devastating to my client, but something else maybe. So we want to make sure we have open communication with the client. Too many cooks without a chef. This goes back to having a single point of contact. It's important to get multiple professionals on the team, but we want to make sure that there is one person that is coordinating care. Misdiagnosis or assignment of a false diagnosis. You know, sometimes misdiagnosis can be used from using the wrong instruments. It can be a mistake. Sometimes the assignment of a false diagnosis is done to increase reimburse ability, if that's even a word. So if somebody has depression and alcohol abuse diagnosis. I have seen it before where their primary diagnosis would flip flop as soon as they ran out of benefits for one, they would switch over to benefits for the other. Intimidation. We don't want to intimidate clients to say you will agree that you've got this diagnosis. Overtreatment. I already talked about that. Not only is overtreatment keeping clients in treatment for too long, but also having them go to too many different people to have a nutritionist and a physical therapist and a massage therapist and an acupuncturist and this and that and the other thing. Because insurance will pay for it. Well, let's look at what is the least restrictive environment that we can put this person in and what is it that they feel they need. We don't want to relay false patients. Personal information. You know, we don't want to lie about anything. Unappropriately sharing or distorting information. Again, usually when I've seen this, it's done to increase the severity or the perception of severity of the problem in order to qualify the person for a higher level of care. Ethical issue on so many different levels, but it also does puts a patient in a higher level or a higher level of restriction than they really need, which is not beneficial to the client. Don't treat out of the realm of your expertise. You know, if somebody comes in and they're dealing with a particular issue that you know you don't have training on. This is not the time to wing it. Maybe you say if you start seeing that issue come up, you realize you need CEUs on it so you can help the clients that come in. But if it's a significant issue that they're wanting help with, you don't have the training. You don't want to go there. In Florida, for example, I was a supervisor of our outpatient programs for quite a while. And at one point I was put over a supervisor of children's outpatient, which is great. I had great clinicians, but I have no training in working with kids. Zero. Zilch didn't get any when I was in graduate school, and I hadn't had any CEUs by that point. As an administrator, it wasn't that big of a deal. But when I had to go into a school, if I had to go in to try to fill in for a client, because my supervisor said I had to, you know, I'm sitting there going, ethically, this is not kosher because I can talk to the kid, but this is not treatment. So providing what I ethically settled on from my own piece of mind, providing contact with the child, allowing the child to meet with me, talk with me so they didn't feel like there was an abandonment while their clinician was gone or until we found a new clinician, you know, that was cool, but I couldn't ethically bill it as treatment because I didn't have the expertise. And then during that time, I also sought out supervision from a child therapist in order to bridge that gap. But, you know, sometimes you're going to be put in certain situations that you feel kind of out of your element, and that's the time to seek supervision. Make sure it's documented that exactly what you're going to do to handle your whatever this caseload is or what this client issue is, given that you don't have the training you feel you need. And in order to prevent harm to the client, and that's what it really comes down to. I'm not going to engage in play therapy and assume I know what I'm doing because I could do more harm than good. So it was that's kind of what I'm talking about with realm of expertise. If you're not certified as a in hypnosis, you know, really be careful about what you do in terms of hypnosis and self hypnosis guided imagery anything like that. In many states it's actually illegal and they might consider that, you know, going into an area that you need to have a specialty certification. And it's also a medical error if you don't consult with other medical professionals. If you don't ask, you know, maybe your client starting to have symptoms of serotonin syndrome or maybe they're not responding to their antidepressant, and you just say, well, you know, see your doctor tell them about it, whatever. I have found, even working with clients in the facility I worked at where we had psychiatrists on staff so it was all the same team. They wouldn't many, many times the clients would not advocate for themselves. They got this sort of white coat syndrome, if you will. So many times I would write up a brief bullet point summary of what I was seeing. For the clinicians that were for the psychiatrists that were on our team, I would put it in the chart because I knew they had to read that if the person's physician or psychiatrist was outside of our team. I would often give it to the patient and go hear the talking points and encourage them to present it to their physician. And most of the times that would go really well. Because they felt like, all right, here's what I need to say. And so I don't feel like I'm stammering. And, you know, I would also call their physician if they wanted me to. But most of the time I really wanted them to start learning to advocate for themselves. We really collect background histories and do complete assessments again to rule out any other things that might be causing the symptoms or any other treatment issues that might be concurrent. We need to make sure that we provide a safe and secure physical environment so clients aren't scared so clients aren't, you know, having problems or getting assaulted in our waiting room or something. We don't want to recommend inappropriate or dangerous treatment protocols and put people out there recommending things that have not been through clinical trials. It's important that we let them know the risks of any treatment in an informed consent and stick with best practices. So what are the effects? Loss of trust leads to dropout and often relapse or symptom worsening. The loss of trust that happens when there's a medical error causes a lot of problems, not only for the client, you know, not wanting to go back to a therapist going, well, that didn't work. But it can cause them medical complications and psychiatric complications. It's important that we make sure that clients are open to communication. We don't want them to take incompatible medications due to lack of communication by the patient's various providers. So if we're not communicating, since we're not prescribing, it's not as much of an issue for us. But if we hear that she's got a pain management physician over here and a psychiatrist over here and they don't know about each other, we know that opiates and SSRIs do not mix most of the time. So we want to make sure that the patient knows the potential dangers and encourage the patient to connect those two providers. Clients may abuse medications or take inappropriate medications when multiple causes for emotional or physical pain are not considered. Again, we want to look at what's going on with the client and how can we best help them? When we're talking about medications, a lot of this is referring to prescribing physicians. But it's important because clients spend an hour with us. Clients spend like 10 or 15 minutes with their docs and not nearly as often. So it's important that we keep our ears open so we can sort of bridge the gap. And yes, when you're working in multidisciplinary teams and the team professionals are not within your organization, it can be extremely frustrating to try to get in touch with a doctor or a psychiatrist or a physical therapist. I mean, they've got their own practices, I get it. So it can cause you to have to call a bunch of times. None of that is billable. So if you're in private practice, you're kind of pulling your hair out going, oh my gosh. And I mean, I'm just being realistic here. We do have to look at a bottom line when we're talking about how much time we spend trying to get oriented to a multidisciplinary team. I think, and obviously, which is why I do it, and it's not a professional recommendation. It's just my personal preference is, you know, whenever I'm making a call or I think something needs to be communicated to another provider. Like I said, I usually encourage the patients to advocate for themselves. And this also applies to calls to Department of Children and Families, abuse, mandatory reporting calls. If a client is in my office and I need them to make a phone call or a phone call needs to be made, I often advocate and try to get them to make the call. So it's not me sort of quote, tattling on them. I want them to feel like they're taking proactive movement towards resolving their problems. Another effect of medical errors is the loss of important wraparound services due to poor team communication or lack of necessary paperwork where I used to work. Getting case management was you had to be a magician because so few insurance companies reimbursed for it and even Medicaid where I was from didn't always reimburse for case management. Things had to be written a very specific way. So it was important to communicate and work with the people in the case management department who knew exactly how it had to be worded. It's not like your client needed case management services. And I'm not talking about services they don't need. But I'm talking about making sure that if you feel strongly they need these services, communicating with the people that you're trying to bring on to your team and going, how do I make this happen so you can get paid and the client can get services. You can also lose family support if psychological and financial assistance is withdrawn or reduced through lack of follow up with insurance or completed recommendations by team members. So if you don't get those additional sessions authorized, and the client is not able to see you anymore, you know, you may lose some family support, because you're basically abandoning the client if you're like, oh, I didn't get that authorized. So we're going to have to reschedule for two weeks from Tuesday. That doesn't work. It's important that the client is our priority. And I know getting those authorizations are a bugger and a half. So figuring out a way to work your system. So you do it. I typically, when I have a larger case load of insurance clients, I set aside one day a week, and I go through and I make my calls for all the reauthorizations, because I know I'm going to be on the phone for several hours. The clients can lose the ability to feel psychologically or physically safe if they're pouring out their heart and we're like, oh, I'm going to help you and then we don't do our part. We can see how that could be a problem. Clients may also start to experience anxiety about new or particular environmental settings, or the introduction as of new professionals, as well as treatment protocols, when proper protocols are not followed and referrals are made. If you've worked in community mental health, you know that sometimes it can feel like a revolving door of clinicians. The client doesn't get adequate closure before the new clinician shows up, or if the client gets closure and then it's like six weeks before the next clinician shows up. They may start getting anxiety and getting frustrated because they feel like they've got to start all over again. All right, let me tell you my history. Clients can place themselves in unnecessary physical or emotional danger because of their inability to use sound judgment. If they feel like they are being abandoned, if they don't have someone they can reach out and connect with, they don't have a grounding point, they may be more at risk, which can also worsen existing or create new physical or mental health conditions. Now, we can actually do harm, a lot of harm to our clients through even their perception of abandonment if we weren't intending to abandon them, but we don't follow up when they don't come for three weeks can cause harm. Clients can experience trauma as a result of a medical error, which can cause acute stress issues. So, if that medical error happens to be, for example, not referring to a physician when there is that when there are obvious signs of serotonin syndrome, the client can end up in the hospital and then feel very distrustful of the entire treatment team. They may, clients may take unnecessary personal risks or cause harm to themselves or others if they are feeling unattended to. And sometimes this is a way of getting attention going, hello, here I am. I'm not just a number. So we need to look at how the client might feel. And I always try to put myself in the clients in the client's shoes. When we say we're going to do something, we need to do it. We need to make sure that, you know, basically treat your clients as if the same way you would want another professional to treat your family members. Common issues when we're talking about pain, more than 50% of patients with pain have concurrent depression. So it is not uncommon for us to see clients in a mental health clinic that are also seeing a pain management physician. Be aware of the different types of pain assessment and pain management techniques that the pain physician might be using and try to stay up on, you know, the current trends, not that we're going to tell the doctor what to do. But if the client feels like they're stuck and, you know, they're not making any progress, not feeling any better with this physician, we can help educate them about other potential things that are out there. And, you know, see if they can go talk with their doctor about, well, what do you think about trying this, like physical therapy or yoga or acupuncture. We want to consider how pain influences comprehensive treatment. So from our perspective, pain can influence treatment, compliance and motivation. If you've got a client who wakes up every morning and they're in agony and they're in agony all day long, you know, you know, somewhere between a four and an eight, it can wax and wane a little bit, and then they go to sleep and they don't sleep well because they're in pain. Yeah, they're probably not going to be overly treatment compliant with their mental health treatment plan because they're doing all they can just to get out of bed in the morning, which may lead to self medication with illicit drugs or additional over the counter medications to try to help relieve the pain. It exacerbates anxiety, depression and irritability. We know that the combination, if it's there of serotonin and opiates can prompt serotonin syndrome. We also know that opiates themselves sometimes can do the same thing. So we want to be aware of what's going on and pain causes sleep disturbances. So if you've got a client who's not getting enough sleep, we know the brain rebalances neurotransmitters when we sleep. So if they're not seeing improvement and they're continuing to have sleep problems, that may be a medical issue that needs to be addressed by the pain management, pain management physician or the regular physician. Symptoms requiring urgent action. These are all pretty, you know, of course, suicidal, homicidal feelings, sudden severe pain, signs of serotonin syndrome, remember, can cognitive, autonomic and neurological symptoms. Head or spine injury, if they fall down in your clinic or they tell you that they fell down while they were at work and they start acting kind of off, get confused easily, they may have a head injury. And it's important that we ensure that they get referred to a physician. Obviously, bleeding that won't stop is going to be a problem, swallowing a poison, cool, clammy, pale skin, you know, if they start feeling like that, there's something going on and they need to be referred to a physician. Sudden changes in consciousness or confusion. There's a whole bunch of things that could cause that, none of which we as non prescribing, non medical professionals are going to be able to deal with. We need to refer out. If they are coughing up blood, report persistent night sweats or have unexplained fever. There may be tuberculosis. Most states require that you go through tuberculosis assessment training every two years or at least when you first get your license. So you're probably familiar with this. But do be aware of the signs of TB because it's certainly not something that's eradicated. If they're having symptoms or heart attack or stroke, we don't want to assume that they're just confused, they're having a bad day, they're intoxicated or having a panic attack. If there are signs of any of these, you know, it's probably better to have ambulance come out or have them go to the emergency room, rather than just assume that yeah, it's just a panic attack. Because that can put you in really dangerous territory. So prevention of errors, single point of contact have procedures for conducting and reviewing assessments and clinical histories. So everybody on the team actually has to read it. Which if you're dealing with people who are not in your organization can be a little bit more difficult with EHRs. It's better because you can get them access to that assessment. But getting them to read it, that's a different story. Policy for communication with team members and referral sources. How often do you follow up with the physician? How often do you follow up with the physical therapist? Depending on the acuity of the issue, it may be weekly, but usually it's probably going to be a monthly thing when you're doing your treatment plan reassessment. You want to have a policy for that though. Multi-disciplinary policy regarding abbreviations, informed consent procedures. Make sure the client knows what they're consenting to, who you can talk to with and without a release of information. A comprehensive non-punitive risk management and incident reporting policy. So people on your team are actually going to report problems when they happen instead of going, oh crap. If somebody finds out about this, I'm going to lose my job, so I need to try to cover it up. It happens. And I would much rather, from a supervisor standpoint, I would much rather know that something happened so I can deal with it and the person can learn from it than have them freak out. And, you know, most of the time it's not a fireable thing. Most of the time, even if it's an egregious error, it is not something they did to intentionally hurt the client. Mutual respect and open communication with teams. Yeah, that goes without saying. Annual staff training on signs of medical emergencies and emergency procedures. This includes your front desk staff. If you have an office, even a private practice, make sure that your receptionist can identify signs of intoxication, serotonin syndrome, heart attack, stroke. Know how to do a basic pain assessment. If you are car for credited, you're very familiar with this. Know what common medical errors happen related to pain management and the impact of pain on your treatment. You know, how is somebody going to comply with your treatment if they're in a lot of pain, or if they are on opiate based medications or gabapentin or something else. Know what the side effects are so you can work with those clients in an individualized fashion. And make sure everybody knows the signs of addiction and substance impairment. Get regular supervision to not only your clinicians, but again, your front desk staff, anybody who comes in contact with clients to make sure everybody's on the same page. Yes, your receptionist is not on the multidisciplinary team, but he or she is likely going to be the one that handles the phone call if they're going to cancel who handles the phone call or sees the client when they first come in. So they can provide you valuable information that may not get translated once they're in your office, because I see this Jekyll Hyde thing where they act one way in the waiting room. And then, and I hate to call it white coat syndrome, but it's kind of the same thing when they get into your office. It's much stiffer sometimes, especially during initial assessment. Make sure your staff has reasonable case loads. In my personal opinion, having 30 billable hours a week is a little excessive. I know that's what a lot of treatment centers require. Know what's reasonable for you. If you're in private practice, you have the luxury of adjusting those numbers a little bit. And make sure your administrative policies focus on the well-being of the client over profits and billable units. I just went to a doctor Monday. And my appointment was at 1045. At 1120, I got up and I was like, I'm leaving. I might call and reschedule. In reality, I'm not going to call and reschedule. Because it was clear to me by that physician running so late, nobody coming out and going, you know, I'm sorry, running a little bit late, that I was just a number. So when clinics double book people or book people back to back to back, knowing you're going to end up running late, that can communicate to the client that they are not important to you. So, and profits and billable units are more important. So you want to look at your administrative policies and see what are we communicating to clients. Root cause analyses love these things. I hate doing them. Don't get me wrong. But it is an interesting exercise, especially if you're doing it hypothetically. You have a problem and it's significance. And then you identify causative factors. So a root cause analysis of, you know, one particular unit, for example, not making their billable hours. You know, that's not something where somebody is getting harmed, except for, you know, the agency is not making enough money. So I want to look at what's the cause of this. Are there regulatory changes. Was their frequent change where their frequent changes in policy or procedure was the work environment chaotic. Was the poor communication in the team environment so some things that could have been billed for weren't billed for. Were a lot of people on vacation and staffing what you were understaffed. What things happened that led to paybacks. And what are the patient characteristics that you are looking at. So then you can say, All right, if we're dealing with clients that are, you know, in this particular population, for example, at one of my outpatient rural clinics. When I when I worked in Florida. There was a whole different set of things we needed to consider in order to make sure that we got billed and we were able to see those clients and we were able to provide them continuity of care. Then for the clients that came to our main campus, which was in the big city of Gainesville. So understanding what is the root cause of this problem and it's not always a client death or a client injury. Sometimes it's a fiscal problem. But if you have enough fiscal problems, you can't keep the doors open, which then becomes a client problem. Root cause analysis identify the relationships between the causative factors and the problem. So what caused it, you know, what things can we look at that can be identified. We want to identify solutions to correct or prevent further occurrence of the causative factors, if possible, you know, some things you're just going to have. And there's no way to prevent them completely, but you can mitigate them some. You want to review the potential impacts of the solutions. So if you say, well, we don't want to have paybacks. So after you do your notes, you're going to have your supervisor review them and sign off on them. Then you're going to have the second level supervisor review them and sign off on them. Well, yeah, that's probably going to prevent paybacks, but that's also going to leave you spending a whole lot of money on reviews, which is probably more than the payback itself. And it gets quite cumbersome and can prevent communication among the team if files are always stuck in the review process. Yeah, that's personal experience there. Then you decide on a course of action. Once you figure out what things you're going to implement and which areas you're going to say, you know what, we're just going to have to accept that this might come back. Decide on a course of action, document the problem, the causes, the solutions, and the relationship between the causes and the problem and the causes and the solution. So you can see why you're doing these things. When I used to go back to my staff, I was always middle management. So when something would change, when the policy would change, especially if it caused them more work, they would want to know why are we doing this, we already got have too much to do why. So it's important to be able to articulate it in a good root cause analysis if it's going to cause a change in policy or procedure will identify the wise. So an integrated comprehensive system of care is important to ensure appropriate and effective documentation and communication between clinicians. And I use that term loosely, MDs, nutritionists, physical therapists, everybody on the team. We want to make sure everybody has the ability to be on the same page. And like I said, if they are outside of your agency, you can't force them to read an initial the client record, you can't force them to do anything. Best we can do is have and usually we are the single point of contact. Again, because we see clients once a week for an hour, or, you know, three times a week for an hour for group or something. We see the clients a whole lot more frequently so we're often sort of the person is probably best poised to say we need to make a referral here we need to follow up on this referral. It's important to understand though that medical errors can occur in many settings. So even though you may not have committed the medical error or however you want to say it. If somebody that you referred to made a decision and it resulted in a medical error that also reflects on you whether you like it or not it reflects on the entire. What's the word I'm looking for profession. It's not just you as a person, but it's like well I can't trust those medical people. We need to recognize that and just understand. So if something happens, whether it's because of something you did or didn't do or something somebody else on the team did or didn't do, then we need to address it with the client and allay some of those fears and try to reestablish trust. A medical error cause causes or has the potential to cause physical psychological social or financial harm to a client and financial harm can be because they decompensate and they have to be hospitalized and lose time at work. It can also be financial harm if we don't get the reauthorization done and insurance won't cover their last 11 sessions or something. And you go to them with a bill and go well insurance said they won't cover it so now you owe me a whole bunch of money. Well that's financial harm, especially if they are assuming that, you know, if you did your job right that the insurance company would pay for it. We also need to remember that medications can both be a solution and the cause of many problems. So, you know, it's a it's a double edged sword, which is why we want to communicate with our clients. I found working with with clients over the years. Many of them are more willing to talk with me about problems they're having with their medication or lack of improvement, even when they're on a medication. Then they are with the physician and their feeling is well my physician knows best so if they say this is what I need to be on it's what I need to be on. And yeah, that might be true. The physician definitely is much more educated in terms of medical stuff, but they, the clients are much more educated in terms of what works for them. They've lived in their own skin for 20, 30, 40 years. They know what works and if they don't feel that it's improving, you know, we can educate them like with SSRIs it may take six to eight weeks to really feel an improvement. But by the same token, if there are what my son's physician used to call unacceptable side effects that would lead to treatment discontinuation or non-compliance, we want to make sure that they understand that it's okay to tell your doctor. This isn't working for me and actually encourage them. And, you know, we're not going to go to the appointment with them most likely. But we can provide them a written synopsis. We can, if they want us to reach out to their physician, let them know that there might be a problem, maybe send them a secure email with the chart notes or summary indicating that there's a problem. So they are aware of it. So there are things we can do. You just have to figure out what you have the time and ability to do in order to facilitate communication and help your clients feel empowered to take control of their own treatment. Professionals must be aware of the signs of medical emergencies. A comprehensive risk management plan is essential to the prevention of medical errors. And we do have videos on our YouTube channel on risk management and disaster planning. You know, I think it's important. Those both of those things are really important whether you're in a single person private practice or in a community mental health center. So understand what potential risks are there. So you can do a root cause analysis on those things and prevent them so they don't ever have an opportunity to negatively impact your clients. So effective root cause analysis examines the identifiable and preventable causes of problems identifies any solutions that are realistic documents and implements them. Are there any questions. Okay, well I really appreciate you guys being here on this kind of odd day since yesterday was a since yesterday was a holiday if you have any questions. You can email me at support at all CE use calm. There's two of us in the office so if it's not a technical question he's going to pass it on over to me anyway. And I will answer it as soon as possible I know we went over a lot of stuff and you know medical errors can be kind of dry so you know I appreciate you sticking with me through that. And so if there are no questions then I will see y'all on, I guess tomorrow, which is Thursday. If you enjoy this podcast please like and subscribe either in your podcast player or on YouTube. 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