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Executives Can and Should Prevent Clinical Mistakes
Clinical mistakes can result in damage to patients, clinicians, and healthcare systems. The consequences of errors range from poor clinical results to malpractice actions. The behavioral field copes with an additional danger since some patients who deteriorate pose a risk of suicide. While one might expect preventing mistakes to be a high priority, relatively simple methods are rarely used.
Is our field less preoccupied with mistakes than others? While physicians are trained to fear medical mistakes, most non-MD clinicians are less wary. A physician reflecting on her education noted that a supervisor once insisted, “you must never stop being terrified.” The fear of overlooking a detail, waiting too long to act, or making the wrong judgment is bred into each doctor.
This mentality may be inculcated less vigorously with therapists. The work is quite different. Therapists work within the subjectivity of communication while physicians deal in objective measures and procedures. Of course, the fear of error is magnified for the therapist when the risk of violence emerges or other extreme symptoms appear, but many therapists encounter such extremes infrequently.
Mindset is only part of the issue. The fear of mistakes is a poor guard against committing them. A landmark 2000 study by the Institute of Medicine taught us that systems rather than people should be our focus if we wish to reduce clinical mistakes. Unfortunately, there is still an urgent need to design a safer healthcare system.
Our field can change, and we can start by accepting that safety needs new champions for improvement. We can no longer passively hope this becomes a higher priority for clinicians. Shame and blame rarely is a good strategy. We need behavioral healthcare executives to take the lead and implement new safety systems. Fortunately, well-researched options are already available.
Michael Lambert helped shape the domain of psychotherapy outcomes research, focusing on “client-centered research.” As opposed to studying treatment and control groups, he asked if this therapy is working for this client. He discovered that measuring outcomes routinely during treatment could identify clients with a high likelihood for deteriorating and dropping out of treatment prematurely.
These individuals show escalating levels of psychological distress during treatment, and this worsening state increases the risk for adverse events like hospitalization and suicide. Dr. Lambert’s research focus includes giving very simple feedback (i.e., on track vs. off track) to clinicians to change course and avert an impending crisis. His research clinic did this consistently, but it happens rarely in the real world.
Lambert found therapists to be generally positive about treatment (not “terrified” like MDs) and prone to missing potential failures. He argued 20 years ago that treatment systems should focus on clients who are responding poorly. This is a key aspect of measurement-based care (MBC). What should be done when a potential bad outcome is identified? His later work addressed useful interventions.
Clinicians have failed during the past 20 years to measure outcomes, let alone intervene when problems are flagged. It is time for executives to start managing risk. This is a natural duty for them, as well as a routine benefit for clinicians practicing in clinic settings. New analytics help us target clinical outliers and design healthcare settings in which additional services are reserved for the most vulnerable.
What does the handoff from clinician to executive involve? Clinics must have systems to administer, score, and push results to clinicians for every patient. This is how Lambert’s university clinic was designed. Technology can facilitate each step of the process to ensure the burden is low for all involved. The percentage of cases needing intervention will vary by clinic based on the severity of the case mix.
The statistical analysis at the heart of such a system is beyond the expertise of either the clinician or the executive, but it is reasonable for executives to implement such specialized enhancements as part of running a first-rate care delivery system that avoids errors.
When ownership is at the clinic rather than clinician level, a range of interventions can be developed. Everything from consultation by senior clinicians to the introduction of digital therapeutics can be considered. Clinician resistance is less likely when clinic policy is involved.
The clinician is still in charge. MBC is comparable to pilots having more gauges and controls in the cockpit. We need to design the modern therapy cockpit in a collaborative way that better manages risk and improves the overall experience. For example, a meta-analysis of 58 research studies recently found a significant improvement in clinical outcomes from giving clinicians feedback on clinical progress.
Executives can take charge of providing timely feedback and seamlessly augmenting care with an array of services. Good systems make good clinicians better. We can end the historical misunderstanding that has restricted responsibility for clinical activities to clinical personnel.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
Disclaimer: The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
Lamas DJ. The cruel lesson of a single medical mistake. New York Times. Published April 15, 2022.
