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Medical Errors
As Required Per Florida Statute 456.13(7)
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Florida Statute 456.013(7)
The board … shall require the completion of a 2-hour course relating to prevention of medical errors as part of the licensure and renewal process.
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Florida Statute 456.013(7)
The 2-hour course shall count towards the total number of continuing education hours required for the profession.
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Florida Statute 456.013(7)
The course shall be approved by the board or department, as appropriate, and shall include a study of root-cause analysis, error reduction and prevention, and patient safety.
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Purpose
The purpose of this course is to view the prevention of medical errors and includes the perspective of mental health professionals, psychologists and dieticians.
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Objectives
At the conclusion of this course, the participants will be able to: – Identify major causes of medical errors
conducted by health professionals.
–Describe the effects of medical and mental errors on patient safety and care.
– Identify approaches to prevent and correct errors.
–Describe methods to keep both clients and providers safe.
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Erring on the Side of Human
Factors for Patient Safety (APA, 2007, Institute of Medicine Report)
On December 7, 1999, the Institute of Medicine (IOM) dropped a bomb during what would have been a quiet congressional recess.
The "bomb" was a report entitled "To Err is Human: Building a Safer Health System," identifying medical error as the third leading cause of death in the United States.
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Medical Errors
Medicine has traditionally treated errors as failings on the part of individual providers, reflecting inadequate knowledge or skill. The systems approach, by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems. (AHRQ, 2012)
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Complexity of Medical Error and Injury Issues (APA, 2007)
Medical error is usually the result of a confluence of circumstances rather than simply one person making a mistake, so reducing medical error and injury cannot be accomplished simply by identifying and punishing individuals who have made errors.
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Complexity of Medical Error and Injury Issues (APA, 2007)
Instead, most experts believe that reduction depends on addressing error systemically.
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Complexity of Medical Error and Injury Issues (APA, 2007)
That is, it depends on understanding the relationship between proximal and distal causes of error and altering the causal stream, so that errors are not facilitated.
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Complexity of Medical Error and Injury Issues (APA, 2007)
Reduction of error and injury also depend on understanding success, since medical-setting studies show that far more accidents are waiting to happen than actually happen.
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Complexity of Medical Error and Injury Issues (APA, 2007)
Clearly, error in medicine (as in any complex system) involves understanding how people perform, how people think, how people communicate with one another, and how people interact with technology in complex organizational systems.
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Complexity of Medical Error and Injury Issues (APA, 2007)
So a systems approach to understanding both safety and error involves multiple domains within scientific psychology.
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Medical Errors
This systems approach to reducing error makes sense to all of us in the fields of social work, mental health and psychology.
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Medical Errors
It fits well with how we typically conceptualize problems.
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Medical Errors
Medical errors can be broken down into 2 types
Acts of commission
Acts of omission
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Medical Errors
Acts of commission
–These are things that you DO which are mistakes
–Examples of acts of commission would include:
Incorrect diagnosis
Sexual misconduct
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Medical Errors
Acts of omission
–These are things that you FAIL TO DO that are expected
–Examples of acts of omission would include:
Failure to keep adequate records
Failure to report child abuse
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Medical Errors
Both acts of commission and omission are judged against prevailing standards of practice for your profession
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Medical Errors
Simple steps
–Become a member of your professional organization
–Read board findings / minutes
–Keep your professional skills current
–Use supervision regularly
–These steps can make you aware of the mistakes of others in your field and help you avoid them
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Potential Errors within a
Psychological Setting
Florida Board of Psychology finds each of these errors so serious, they are specifically mandated as content within this course . . .
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Potential Errors within a
Psychological Setting
Inadequate assessment of suicide risk
Failure to comply with mandatory abuse reporting laws
Failure to detect medical conditions presenting as a psychological disorder
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Inadequate Assessment
Of Suicide Risk
This may be the worst case scenario for medical errors
–Risk of death is high
–Professional responsibility to assess risk exists
–Use Florida Baker Act for imminent risk
–When in doubt - Consult !
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Failure To Comply With Mandatory
Abuse Reporting Laws
Psychologists, social workers and other mental health professionals are trained to identify child and elder abuse
Although other professionals are required to report suspected abuse, clearly those in mental health understand the importance
When in doubt, report suspicions
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Failure To Detect Medical Conditions
Presenting As A Psychological Disorder
Many psychological disorders present with physical symptoms that are associated with medical conditions
First rule out all medical conditions by referring to the appropriate medical specialty
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Failure To Detect Medical Conditions
Presenting As A Psychological Disorder
For example
–if a client presents with heart palpitations and shallow breathing, treatment for panic attacks is only appropriate after it is determined that they do not have a heart condition
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Failure To Detect Medical Conditions
Presenting As A Psychological Disorder
For example
–if a client presents with trouble sleeping, loss of interest and weight loss a diagnosis of depression is only appropriate if they do not have a medical illness causing these symptoms
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Worst Case Scenarios
Death of a Client - Could be due to either acts of commission or omission
Medical errors that result in –Suicide
–Homicide
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Suicidal Clients
Medical errors with suicidal clients
–Failure to properly diagnose
–Failure to properly treat
–Failure to Baker Act when appropriate
– Improper use of contracts
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Homicidal / Violent Clients
Medical errors with homicidal or violent clients
–Failure to diagnose accurately
–Failure to properly treat
–Failure to Baker Act appropriately
–Failure to exercise Duty to Warn
– Improper use of contracts
–Failure to separate violent clients
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Homicidal / Violent Clients
Duty to Warn
Duty to Protect -
– In Florida this usually means Baker Act
Tarasoff applies
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Practice Guidelines
Exercise proper professional care
This includes:
–Referring out when you do not have the expertise to treat effectively
–Seeking supervision and consultation
–Updating your own clinical skills to keep up with scientific advances in the field
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Practice Guidelines
Consult when necessary
It is good practice to consult with an experienced clinician regularly and often
–Discuss difficult cases
–Seek advice / expertise
–No one can be an expert at everything
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Practice Guidelines
Take careful histories and advise clients:
–Fully informed consent
–Limits of confidentiality
–Have signed forms on file
–Rights and responsibilities
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Practice Guidelines
Document all interventions
– Inadequate records can easily result in medical errors
–Failure to maintain sufficient client records can lead to difficulty with the board
–Client record requirements will be reviewed in detail later in this presentation
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Practice Guidelines
Create and follow a clear protocol regarding duty to warn and contingency plans
–Develop protocols for all high risk situations that you are able to predict in advance
–These protocols will vary from agency to agency and population to population
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Practice Guidelines
Develop risk management procedures
– If you have difficulty generating procedures, read – practice guidelines for most situations are easy to find from your professional organization
– It is easier and safer to develop these procedures when there is no crisis to be resolved immediately
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Expressed & Informed Consent
Expressed and Informed Consent is: - Consent voluntarily given in writing,
by a competent person, after sufficient explanation and disclosure of the subject matter involved to enable the person to make a knowing and willful decision without any element of force, fraud, deceit, duress, or other form of constraint or coercion.
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Expressed & Informed Consent
What does incompetent to consent to treatment mean?
- A person’s judgment is so affected by his or her mental illness that the person lacks the capacity to make a well-reasoned, willful, and knowing decision concerning his or her medical or mental health treatment
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Psychotherapist – Client
Relationship
This relationship is established once services, psychotherapy, counseling, assessment or treatment are rendered
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Psychotherapist – Client
Relationship
A contract, scheduling of appointments, or payment of a fee are not necessary conditions to establish that a relationship exists
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Psychotherapist – Client
Relationship
This relationship once established is deemed to continue for a minimum of 2 years after the termination of psychotherapy or the last date of professional contact with the client
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Client Records Requirements
Psychological Report, Psychosocial or Assessment
Treatment Plans
Progress Notes
Discharge Summaries
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Client Records Requirements
Basic client information
Treatment or evaluation session dates, including cancellations and phone contacts
Diagnosis, if applicable
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Client Records Requirements
Interventions and results
Client’s consent documents, releases, and consultations
Financial transactions
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Client Records Requirements
For social workers, mental health counselors and marriage and family therapists
Records must be kept for 7 years after termination
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Client Records Requirements
Psychologists must keep all records for 3 years – after 3 years, they may keep a summary of the record.
The summary must be kept for 7 years after termination
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Confidentiality, Record Keeping,
Mandatory Reporting
Confidentiality Waivers refer to Ch. 394.4615
Confidentiality has its limits
Clients must be fully informed to make informed choices
Documentation must be thorough
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Limits to Confidentiality
Duty to warn
Mandatory reporting – Child / Elder abuse and neglect
Multidisciplinary teams
Supervision
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Limits to Confidentiality
HIV patients
Minors’ records
Group counseling
Health plans’ information gathering
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Mandatory Reporting
Children, Elderly, Disabled Adults
–Abuse
–Neglect
–Abandonment
Death
For some disciplines (medical)
–Threats to public health (STDs)
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Mandatory Reporting –
Chapter 39.201
Chapter 39.201 requires mandatory reporting of child abuse, abandonment, or neglect; mandatory reports of death; central abuse hotline
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415.101 Adult Protective
Services Act
415.1034 Mandatory reporting of abuse, neglect, or exploitation of vulnerable adults; mandatory reports of death.
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415.101 Adult Protective
Services Act
415.104 Protective investigations of cases of abuse, neglect, or exploitation of vulnerable adults; transmittal of records to state attorney.
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Title XXIX Chapter 394 The
Florida Mental Health Act
AKA
“The Baker Act”
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Mental Illness – Definition
[F.S. 394.455 (18)]
Impairment of the emotional processes that exercise conscious control of one’s actions or of the ability to perceive or understand reality, which impairment substantially interferes with a person’s ability to meet the ordinary demands of living, regardless of etiology.
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Mental Illness – Definition
[F.S. 394.455 (18)]
For the purposes of this part, the term does not include retardation or developmental disability as defined in Chapter 393, intoxication, or conditions manifested only by antisocial behavior or substance abuse impairment.”
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Disciplinary Guidelines, Board
Orders
Please refer to F.S. 490
Review of guidelines, probable cause,
title violations, violations of descriptive
terms of service, minor violations,
citations, sexual misconduct, terms of
probation, mediation offenses, and
supervision by disciplined practitioner.
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Sexual Misconduct
Defined by Chapter 64
It is sexual misconduct for a psychotherapist to engage, attempt to engage, or offer to engage a client in sexual behavior, or any behavior, whether verbal or physical which is intended to be sexually arousing including kissing, sexual intercourse, (etc).
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Prevention And Analysis
Root-cause analysis
Error reduction & prevention
Patient Safety
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Root Cause Analysis
Root cause analysis helps identify what, how and why something happened, thus preventing recurrence.
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Root Cause Analysis
Root causes
–Are underlying
–Are reasonably identifiable
–Can be controlled by management
–Allow for generation of recommendations
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Root Cause Analysis
The process involves data collection, cause charting, root cause identification
Recommendation generation
Implementation
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Root Cause Analysis
Example
Understanding why an event occurred is the key to developing effective recommendations.
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Root Cause Analysis
Example
Lets suppose that you have a practice that includes a lot of patients with the diagnosis of Major Depression
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Root Cause Analysis
Example
Now lets suppose that you do your own billing and that it requires that you enter the DSM diagnostic code
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Root Cause Analysis
Example
What if you enter the code incorrectly?
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Root Cause Analysis
Example
And based on the DSM diagnostic code, the client’s claim for insurance is denied.
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Root Cause Analysis
Example
Because insurance companies often deny claims for mental health.
You assume that they will not pay for treatment.
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Root Cause Analysis
Example
You inform the client that their insurance claim was denied.
They report that they are sure that they have coverage for mental health services.
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Root Cause Analysis
Example
Some possible recommendations might be . . .
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Root Cause Analysis
Example
Private pay for treatment
Use a short term treatment plan
Refer to a mental health center for treatment
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Root Cause Analysis
Example
But in reality, it was a medical error that is the problem.
And a root cause analysis can help to determine the source of the error.
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Root Cause Analysis
Example
Root Cause Analysis theory states that generally, mistakes do not just happen but can be traced to some well-defined causes.
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Root Cause Analysis Another Example
Identifying that poor insurance coverage is the problem does not help.
Mainly because nothing can be done about a client’s insurance coverage.
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Root Cause Analysis
Root cause analysis investigates to determine why an error took place and what the organization can do to prevent recurrence.
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Error Reduction and
Prevention
Identifying root causes is the key to preventing similar recurrences.
If you are able to determine that the source of the problem is that the diagnostic code was entered incorrectly – you solve the problem.
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Error Reduction and
Prevention
An added benefit of an effective root cause analysis is that, over time, the root causes identified across the population of occurrences can be used to target major opportunities for prevention and improvement.
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Error Reduction and
Prevention
In this example, you can establish a procedure for checking the DSM diagnostic code before submitting an insurance claim.
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Error Reduction and
Prevention
When this procedure is applied to all of your clients, insurance claims are less likely to be denied when they should be paid.
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Patient Safety
“First, Do no harm”
Act within your scope
Follow Code of Ethics
Seek supervision
Contract when appropriate
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Checklists
“A checklist is an algorithmic listing of actions to be performed in a given clinical setting, the goal being to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering and have played a major role in some of the most significant successes achieved in the patient safety movement.” (AHRQ, 2012)
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Checklists
Used by pilots in pre-flight to find defective equipment, identify potential problems and improve safety
Recent studies have found that checklists improve patient outcomes when done before surgery (AHRQ, 2012)
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Checklists
“The field of cognitive psychology classifies most tasks as involving either schematic behavior, tasks performed reflexively or "on autopilot," or attentional behavior, which requires active planning and problem-solving.” (AHRQ, 2012)
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Checklists
“Failures of schematic behavior are called slips and occur due to lapses in concentration, distractions, or fatigue, whereas failures of attentional behavior are termed mistakes and often are caused by lack of experience or insufficient training.” (AHRQ, 2012)
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Checklists
“In health care, as in other industries, most errors are caused by slips rather than mistakes, and checklists represent a simple, elegant method to reduce the risk of slips.” (AHRQ, 2012)
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Checklists
“By standardizing the list of steps to be followed, and formalizing the expectation that every step will be followed for every patient, checklists have the potential to greatly reduce errors due to slips.” (AHRQ, 2012)
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Checklist Controversies
“Checklists are a remarkably useful tool in improving safety, but care must be taken not to overemphasize their importance: they cannot solve every patient safety problem, and even when checklists are appropriate, certain co-interventions may be necessary to maximize their impact.” (AHRQ, 2012)
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Checklists Controversies
However, “only certain types of errors can be prevented by checklists: errors in clinical tasks that involve primarily attentional behavior (such as diagnostic errors) require solutions focused on training, supervision, and decision support rather than standardizing behavior.” (AHRQ, 2012)
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Human Factors Engineering
“Human factors engineering is the discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments.” (AHRQ, 2012)
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Teamwork Training
Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. The need for improved teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings.
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Safety Culture
High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work. Such organizations establish a culture of safety by maintaining a commitment to safety at all levels, from frontline providers to managers and executives. (AHRQ, 2012)
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Conclusion
Medical errors are preventable.
Medical errors should be conceptualized systemically.
Root cause analysis can be used to develop recommendations
Follow professional practice guidelines to reduce error
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Conclusion
Professional practice guidelines require that you:
–Act within your scope and expertise
–Keep current with continuing education
–Follow your Code of Ethics
–Seek supervision/consultation when appropriate
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References
Agency for Healthcare Research and Quality. (2012). Patient Safety Primers. Retrieved
from: http://psnet.ahrq.gov/primer.aspx?primerID=14 on 08/20/2012.
Agency for Healthcare Research and Quality. (2012). Patient Safety Primers: Checklists. Retrieved from: http://psnet.ahrq.gov/primerHome.aspx on 08/23/2012.
Agency for Healthcare Research and Quality. (January, 2007). Care of adults with mental health and substance abuse disorders in U.S. Community Hospitals. AHRQ Publication No. 07-0008.
Agency for Healthcare Research and Quality. (March, 2005). 30 safe practices for better health care. AHRQ Publication No. 05-P007
Corey, G; Corey, M.S. & Callanan, P. (2007). Issues and ethics in the helping professions. Belmont: Thomson: Brooks/Cole.
Gosbee, J. (2012). (2012). Human Factors Engineering Can Teach You How to be Surprised Again. Agency for Healthcare Research and Quality. Retrieved from: http://webmm.ahrq.gov/perspective.aspx?perspectiveID=32 on 08/20/2012.
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References
National Academy of Sciences (n.d.) Free executive summary: To err is human: Building safer health system. Retrieved October 2005 from http://www.nap.edu/catelog/9728.html
Rivas-Vasquez, R. A., Blais, M.A., Rey, G.J. & Rivas-Vazquez, A.A. (2001). A brief reminder about documenting the psychological consultation. Professional Psychology: Research and Practice, 32(2), 194-199.
Rooney, J.H. & Vanden Hevel, L.N. (July, 2004). Root cause analysis for beginners. Quality Progress. pp. 45-53.
University of South Florida: Louis de la Parte Florida Mental Health Institute. (Oct, 2005). Policy Brief. Suicide risk in the Florida Medicaid population.
Tarasoff v. Board of Regents of the University of California, 17 Cal. 3d 425, 551 (1976).
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Florida Statues and Rules
Florida Statutes (F.S.):
– 39 Proceedings Related to Children – 90.503 Psychotherapist-Patient Privledge – 394 The Florida Mental Health Act or Baker Act – 415 Adult Protective Services Act – 490 Psychological Services – 491 Clinical, Counseling and Psychotherapy Services
Florida Administrative Code (FAC) :
– 64B4 Board of Clinical Social Work, Mental Health Counseling and Marriage and Family Therapy
– 64B19 Board of Psychology
Current Florida Statues and Administrative Code can be found at
www.leg.state.fl.us/statutes/index.cfm?Mode=View Statutes&Submenu=1&Tab=statutes
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Florida Statues and Rules
Current Florida Statues and Administrative Code can be found by clicking the link below:
Florida Statues
If you are having problems with the link - copy and paste this address into
a web browser: http://www.leg.state.fl.us/statutes/index.cfm?Mode=View
Statutes&Submenu=1&Tab=statutes
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