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Medical errors in the general medical sector result in significant patient deaths and injuries, as well as high costs to the health care system. Despite the growing literature on errors in medical and surgical specialties, few studies have examined the incidence, nature, predictors, and prevention of errors that may occur in mental health treatment settings. The purpose of the current review is to examine the lessons learned from patient-safety research in the general medical sector, provide examples of types of errors in psychiatry, review the errors identified in the literature, offer a discussion of error-reduction strategies for improving patient safety, and provide recommendations for future research. Increased attention to medical errors in psychiatry is necessary in order to build safer health systems and promote a culture of safety among providers, thereby producing better care for patients with mental disorders. [ABSTRACT FROM AUTHOR]

: Background contextFew empirical data are available that document changes in population-based rates for the evaluation and treatment of nonspecific back pain.: PurposeTo determine the extent of change in the pattern of outpatient evaluation and treatment of nonspecific low back pain in the United States between 1987 and 1997.: Study design and settingThe 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey, two nationally representative surveys with similar sampling methods and questions, were used.: Patient sampleNoninstitutionalized adults in the United States.: Outcome measuresChanges in rates of any health service for nonspecific back pain and occurrence of provider-specific care and types of services provided. Changes in the prescription of specific medication classes (ie, nonsteroidal anti-inflammatory drugs [NSAIDs], muscle relaxants, nonnarcotic and narcotic analgesics) were also investigated.: ResultsOverall rate for outpatient treatment for nonspecific back pain in the US population was relatively stable over the decade (4.48% in 1987, 4.53% in 1997, p = .85). Among those receiving care, the proportion receiving physician care increased from 64% in 1987 to 74% in 1997 (p<.001), whereas those obtaining care from physical therapists increased from 5% to 9% during the same time period (p<.01). The proportion of respondents receiving NSAIDs, muscle relaxants, nonnarcotic analgesics and narcotic analgesics remained stable. However, the mean number of patient visits in which these medications were prescribed increased from 2.0 to 3.9 over the decade (p<.001). The proportion of individuals receiving chiropractic care (p<.01) and X- rays (p<.001) were lower in 1997 than 1987.: ConclusionsThe national pattern of health care for nonspecific low back pain observed in the present study serves as a basis for future investigations into the management of this major public health problem. Findings suggest that perhaps a duplication of care is partly responsible for the high degree of health care utilization in this population. [Copyright &y& Elsevier]

Discusses the most expensive medical conditions in the U.S. Association between spending and disability; Role of the cost-of-illness and burden-of-disease estimates in setting priorities.

Examines the patterns of economic burden across five chronic conditions in the United States. Costs of health care; Characteristics and patterns of service on driving the costs; Comprehension on the needs and improvement of care.

The article highlights the need for greater focus on those at high risk of suicide at a time when the overall annual suicide rate in the U.S. increased to 12.1 per 100,000 persons. Topics discussed include results observed from promising suicide prevention strategies, the opportunity for improvement in patient transitions from inpatient to outpatient psychiatric care in the U.S. and the benefits presented by consolidation of healthcare delivery into larger organizational entities.

Background: The 1990s saw rising numbers of graduates of training programs for nonphysician clinicians, passage of legislation expanding their scope of practice, and a proliferation of managed-care models that emphasized the use of these providers as a strategy for containing health care costs. Methods: We used two nationally representative surveys to examine trends in outpatient care provided by physicians and nonphysician clinicians between 1987 and 1997, adjusting for the case mix. Analyses examined care provided by 10 categories of nonphysician clinicians: chiropractors, midwives, nurses or nurse practitioners, optometrists, podiatrists, physician assistants, physical or occupational therapists, psychologists, social workers, and others. Results: Between 1987 and 1997, the proportion of patients who saw a nonphysician clinician rose from 30.6 percent to 36.1 percent (adjusted relative risk for 1997 as compared with 1987, 1.42 [95 percent confidence interval, 1.35 to 1.50]). The trend was driven by an increase in the proportion of persons who visited both a physician and a nonphysician clinician (from 23.5 percent to 30.9 percent; adjusted relative risk, 1.49 [95 percent confidence interval, 1.40 to 1.58]), rather than an increase in the proportion who saw only a nonphysician clinician (from 7.2 percent to 5.3 percent; adjusted relative risk, 0.81 [95 percent confidence interval, 0.70 to 0.93]). This pattern was consistent in analyses of specific medical conditions and specific types of nonphysician clinicians. There was an increase in the proportion of patients obtaining preventive services from nonphysician clinicians and a decline in the proportion receiving acute care services from such clinicians. Conclusions: From 1987 to 1997, there was a degree of differentiation between physicians and nonphysician clinicians with respect to the services they provided but not with respect to the patients they treated. The implications of these findings hinge on the degree to which the increase in conjoint service delivery represents growing coordination or fragmentation of care. N Engl J Med 2003;348:130-7. [ABSTRACT FROM AUTHOR]

While prior research has identified the impact, nature, and causes of medical error in general medical settings, little is known about errors in inpatient psychiatry. Understanding the broad range of errors that occur in inpatient psychiatry is a critical step toward improving systems of care for a vulnerable patient population. An explorative qualitative analysis of key informant interviews identified a preliminary typology of errors and the contextual factors that precipitate them in inpatient psychiatry. The types of errors and their contextual factors fall broadly within the rubric of categories identified in medicine and surgery. However, many of the specific errors and contextual factors manifest themselves differently and are shaped by the uniqueness of the inpatient psychiatric setting and patient population. Interventions geared toward improving systems of care for psychiatric patients should draw on best practices for safety in medicine and surgery, but also be complemented with new strategies specifically tailored to the inpatient psychiatric setting. [ABSTRACT FROM AUTHOR]

Objective: To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid.Data Source/study Setting: The National Mental Health Services Survey (N-MHSS) 2010-2018.Study Design: A quasi-experimental differences-in-differences design using observational data.Data Collection: The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations.Principal Findings: ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification.Conclusions: This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system. [ABSTRACT FROM AUTHOR]

Objectives This study sought to identify risk factors and protective factors in hospital-based mental health settings in the Veterans Health Administration (VHA), with the goal of informing interventions to improve care of persons with serious mental illness. Methods Twenty key informants from a stratified sample of 7 VHA inpatient psychiatric units were interviewed to gain their insights on causes of patient safety events and the factors that constrain or facilitate patient safety efforts. Results Respondents identified threats to patient safety at the system-, provider-, and patient-levels. Protective factors that, when in place, made patient safety events less likely to occur included: promoting a culture of safety; advocating for patient-centeredness; and engaging administrators and organizational leadership to champion these changes. Conclusions Findings highlight the impact of systems-level policies and procedures on safety in inpatient mental health care. Engaging all stakeholders, including patients, in patient safety efforts and establishing a culture of safety will help improve the quality of inpatient psychiatric care. Successful implementation of changes require the knowledge of local experts most closely involved in patient care, as well as support and buy-in from organizational leadership. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Office visits represent the core component of primary care practice, but little is known about what percentage of primary care provider ( PCP) visit time could be suitable for reassignment to another medical home team member or to a non-face-to-face modality (e.g. secure messaging) in order to optimize face-to-face PCP visit time. Method We videotaped 121 PCP office visits at four Veterans Health Administration Medical Centers and divided visits into discrete activity segments. Two physicians reviewed each visit recording and provided independent clinical judgments regarding which segments might be suitable for reassignment. We examined the activity category distribution of visit time rated as needing face-to-face time with a PCP. Results Reviewers judged 53% of the 5398 minutes of rated visit time as suitable for reassignment to another team member or modality. The percentage of time rated as needing face-to-face PCP care varied greatly by activity category, from a high of 73.9% (for examining patients) to a low of 16.2% (for medication review). Rater agreement regarding tasks' suitability for reassignment varied across activity categories. Conclusions These data offer an example of how face-to-face PCP visit time might be optimized as practices seek to shift components of patient care to other team members and other modalities. Given variations in provider preferences and judgments, successful redesign efforts will need to involve stakeholders in decisions about how to best utilize medical home resources. [ABSTRACT FROM AUTHOR]

Background: Behavioral health organizations are characterized by multiple organizational climates, including molar climate, which encompasses clinicians' shared perceptions of how the work environment impacts their personal well-being, and strategic implementation climate, which includes clinicians' shared perceptions of the extent to which evidence-based practice implementation is expected, supported, and rewarded by the organization. Theory suggests these climates have joint, cross-level effects on clinicians' implementation of evidence-based practice and that these effects may be long term (i.e., up to 2 years); however, no empirical studies have tested these relationships. We hypothesize that molar climate moderates implementation climate's concurrent and long-term relationships with clinicians' use of evidence-based practice such that strategic implementation climate will have its most positive effects when it is accompanied by a positive molar climate.Methods: Hypotheses were tested using data collected from 235 clinicians in 20 behavioral health organizations. At baseline, clinicians reported on molar climate and implementation climate. At baseline and at a 2-year follow-up, all clinicians who were present in the organizations reported on their use of cognitive-behavioral psychotherapy techniques, an evidence-based practice for youth psychiatric disorders. Two-level mixed-effects regression models tested whether baseline molar climate and implementation climate interacted in predicting clinicians' evidence-based practice use at baseline and at 2-year follow-up.Results: In organizations with more positive molar climates at baseline, higher levels of implementation climate predicted increased evidence-based practice use among clinicians who were present at baseline and among clinicians who were present in the organizations at 2-year follow-up; however, in organizations with less positive molar climates, implementation climate was not related to clinicians' use of evidence-based practice at either time point.Conclusions: Optimizing clinicians' implementation of evidence-based practice in behavioral health requires attention to both molar climate and strategic implementation climate. Strategies that focus exclusively on implementation climate may not be effective levers for behavior change if the organization does not also engender a positive molar climate. These findings have implications for the development of implementation theory and effective implementation strategies. [ABSTRACT FROM AUTHOR]