The IOM Committee on Quality of Healthcare in America defines error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim" [1]. It is important to note that medical errors are not defined as intentional acts of wrongdoing and that not all medical errors rise to the level of medical malpractice or negligence. Errors depend on two kinds of failures: either the correct action does not proceed as intended, which is described as an "error of execution," or the original intended action is not correct, which is described as an "error of planning" [1]. A medical error can occur at any stage in the process of providing patient care, from diagnosis to treatment, and even while providing preventative care. Not all errors will result in harm to the patient. Medical errors that do result in injury are sometimes called preventable adverse events or sentinel events. These events are considered "sentinel" because they signal the need for immediate investigation and response [5].

Preventable adverse events or sentinel events are defined as events that cause an injury to a patient as a result of inaction on the part of the healthcare provider or as a result of an action/intervention whereby the injury cannot reasonably be attributed to the patient's underlying medical condition [1]. For example, if a patient has a surgical procedure and dies postoperatively from pneumonia, the patient has suffered an adverse event. But was that adverse event preventable? Was it caused by medical intervention or inaction? The specific facts of the case must be analyzed to determine whether the patient acquired pneumonia as a result of poor handwashing techniques of the medical staff (i.e., an error of execution), which would indicate a preventable adverse event, or whether the patient acquired pneumonia because of age and comorbidities, which would indicate a nonpreventable adverse event.

The Joint Commission is a national organization with a mission to improve the quality of care provided at healthcare institutions in the United States. It accomplishes this mission by providing accredited status to healthcare facilities. Accreditors play an important role in encouraging and supporting actions within healthcare organizations by holding them accountable for ensuring a safe environment for patients. Healthcare organizations should actively engage in a cooperative relationship with The Joint Commission through this accreditation process and participate in the process to reduce risk and facilitate desired outcomes of care.

A root cause analysis identifies basic or causal factors that result in an undesired outcome (adverse event), including the occurrence or possible occurrence of a sentinel event [5]. Based on 2022 data from The Joint Commission, 88% of sentinel events occur in hospitals, emergency departments, or ambulatory care centers. This represents a 19% increase in events from 2021. Leading event types associated with the hospital setting included falls (45%), unintended retention of foreign object (7%), and wrong surgeries (6%). In the behavioral health setting, leading event types were patient suicide (23%), falls (18%), and delays in treatment (16%) [7].

Finally, as previously discussed, after conducting this root cause analysis, the organization must prepare an internal corrective action plan. The Joint Commission will accept this action plan if it identifies changes that can be implemented to reduce risk or formulate a rationale for not undertaking such changes and if, where improvement actions are planned, it identifies who is responsible for implementation, when the action will be implemented, and how the effectiveness of the actions will be evaluated [5].

It is possible that the event with the greatest emotional impact on mental health professionals (and patients' families) is patient suicide. In general, the suicide rate is increasing, with a nearly 37% higher rate in 2022 compared with 1999 [14]. According to a 2010 Joint Commission Sentinel Event Alert, 75% of inpatient suicides occurred in psychiatric hospitals or behavioral health units of general hospitals [15]. The next greatest number occurred in surgical, intensive care, telemetry, or oncology units (14.25%); emergency departments (8%); and home care, rehabilitation units, and long-term or residential care facilities (2.5%). In 2022, 55% of the 73 sentinel events classified as suicide occurred offsite within 72 hours of discharge from an accredited healthcare organization, 40% occurred in an inpatient setting, and 4% while in the emergency department. In the behavioral health setting 23% of sentinel events were patient suicide [7]. General hospitals are inherently less safe for suicidal patients than psychiatric hospitals or units, as they offer the patient more time alone and a number of potential suicide options (e.g., jumping, intentional drug overdose, cutting with a sharp object, hanging, strangulation) and means (e.g., tubing, bandages, plastic bags) that are designed out of psychiatric settings [15].

The Joint Commission recommends a number of risk reduction strategies, including [18]:

There are many suicide risk assessment tools for use by health and/or mental health professionals but few have been tested empirically. If and when they are used, all too often an assessment tool is insufficient in preventing suicide. A thorough assessment by a trained mental health professional is often the best choice, but even these professionals are not infallible. Of those who die from suicide, 20% have had contact with a mental health provider in the last month [14]. Many reasons have been identified for inadequate professional assessments or lack thereof [20]:

Unquestionably, medication errors are one of the most common causes of avoidable harm to patients. These errors may occur at three critical points: when ordered by a physician or psychologist, dispensed by a pharmacist, or administered.

In Florida, as in other states, workers in many occupations are designated as "professionally mandatory reporters" including teachers, nurses, physicians, and law enforcement officials [28]. Social workers, psychologists, and all mental health professionals are included among those who are required to report abuse, neglect, abandonment, and exploitation of children and adults [28]. Additionally, suspected maltreatment is to be reported.

There were 588,229 unique cases of child abuse reported in the United States in 2021 resulting in 1,820 deaths [29]. The vast majority of perpetrators of abuse were parents or legal guardians. Approximately 67% of the referrals of abuse were generated by a mandated professional, including legal and law enforcement personnel (21.8%), education personnel (15.4%), and medical personnel (12.2%). Nonprofessionals submitted 17.1% of reports, with the largest category being parents (6.5%), other relatives (6.2%), and friends and neighbors (3.9%). Unclassified sources submitted the remaining 16% [29].

Only 17.8% of all reports of child abuse or suspected child abuse result in a substantiation or indication of actual maltreatment according to state law [29]. However, this should not discourage the professional from intervening. It is never punishable to submit a report in good faith; furthermore, all reports are confidential (except among protective services personnel) until indicated in a judicial proceeding [28]. In addition to breaching the ethical duty to protect clients from harm (and, subsequently, the professional consequences of this ethics violation), there are legal consequences for those who fail to comply with mandatory abuse reporting requirements. Diligent reporting and documenting of abuse better protects professionals from legal action resulting from inaction.

Adult abuse encompasses self-abuse, domestic abuse, and abuse/exploitation by caregiver(s) of a vulnerable adult [28]. Exploitation refers to the misuse of moneys, taking or selling of property, the inappropriate use of guardianship/power of attorney, and the failure to use the vulnerable adult's funds for their care. A vulnerable adult is defined in Florida as "a person 18 years of age or older whose ability to perform the normal activities of daily living or to provide for his or her own care or protection is impaired due to disability, brain damage, or the infirmities of aging" [28]. Vulnerable adults and children are abused at a rate between 4 and 10 times greater than that of the general population and are themselves less likely to report abuse due to a variety of fears, including not being believed, reprisals, and caretaker abandonment [30]. Mental health professionals are often the individuals to whom the abuse is reported. With the aforementioned statistics and somewhat unique fears in mind, it is reasonable that a slightly higher index of suspicion be employed when working with this cohort.

Emotional changes or suspicious injuries that are noticed in adult clients should be documented and reported. Marks and bruises in various stages of healing should be noted, especially those that resemble objects such as belts or electrical cords or those that reoccur regularly; cigar/cigarette burns; burns in the shape of an object (e.g., clothes iron); missing clumps of hair; marks from being tied down; and other injuries with no reasonable explanation [31]. Other signs of abuse include recurrent poor hygiene among those in the care of others, medical conditions left untreated, food hoarding, age-inappropriate sexual behavior/knowledge of sex, unexplained fear of persons/places, unaccounted for injury or disease of the genitals. Psychological abuse may be harder to detect, but in some cases there are physical manifestations of psychological abuse. Studies of the long-term physical effects of intimate partner violence or child abuse have found an increased risk of asthma, chronic pain, sexually transmitted infections, stomach ulcers, liver disease, and high blood pressure among victims [32,33].

Compliance with abuse reporting laws is not optional, and reporting suspected abuse to a supervisor does not satisfy this requirement [28]. Abuse must be reported to the Florida Abuse Hotline by telephone (1-800-962-2873 or TDD 1-800-453-5145), by fax (1-800-914-0004), or online (https://reportabuse.myflfamilies.com/s/) when knowledge of abuse or suspected reasonable cause exists. Telephone is the preferred contact method and should always be used in emergency situations. It is up to the Florida Department of Children and Families counselors to determine if the report meets the legal requirements for further action [28]. If a counselor refuses the report, a supervisor can be requested for further discussion.

Compliance with abuse reporting laws is not optional, and reporting suspected abuse to a supervisor does not satisfy this requirement [28]. Abuse must be reported to the Florida Abuse Hotline by telephone (1-800-962-2873 or TDD 1-800-453-5145), by fax (1-800-914-0004), or online (https://reportabuse.myflfamilies.com/s/) when knowledge of abuse or suspected reasonable cause exists. Telephone is the preferred contact method and should always be used in emergency situations. It is up to the Florida Department of Children and Families counselors to determine if the report meets the legal requirements for further action [28]. If a counselor refuses the report, a supervisor can be requested for further discussion.

In one study, 3% of psychiatric admissions are actually due to a medical condition; this number is likely higher for older individuals [36]. For example, elderly patients or patients with intellectual disabilities with various infections often present to emergency or urgent care facilities with no other symptoms other than psychosis due to delirium; these infections may be initially overlooked as the healthcare team focuses on the psychological symptoms [37,38]. Urinary tract infections and pneumonia are the most frequent causes of sudden change in mental status in elderly patients, but these patients are often initially diagnosed with dementia based on their age [39]. Other possible causes include electrolyte imbalances, thyroid dysfunction, organ failure, and medications.

In one study, 3% of psychiatric admissions are actually due to a medical condition; this number is likely higher for older individuals [36]. For example, elderly patients or patients with intellectual disabilities with various infections often present to emergency or urgent care facilities with no other symptoms other than psychosis due to delirium; these infections may be initially overlooked as the healthcare team focuses on the psychological symptoms [37,38]. Urinary tract infections and pneumonia are the most frequent causes of sudden change in mental status in elderly patients, but these patients are often initially diagnosed with dementia based on their age [39]. Other possible causes include electrolyte imbalances, thyroid dysfunction, organ failure, and medications.

According to the Institute for Healthcare Improvement, there are approximately 6 million survivors of medical errors each year [40]. As a result of these errors and the way they are handled, patients can lose trust in the healthcare system, and some may never feel a sense of safety in the care of anyone (including mental health professionals) again [41]. These same sentiments can carry over into the psyche of family members and even the general public. Stress reactions, anxiety disorders, worsening of existing mental health conditions, drug dependence, and suicidal ideation may develop in victims of medical errors, even as the result of "less serious" events, such as a breech in confidentiality. Feelings of anger, guilt, loss, and fear may persist long after the event [40].

It is important that patients and professionals understand that risk and trust are a part of everyday life. It is necessary for clients to regain trust or self-trust and learn to rethink in a more complex way. Cognitive-behavioral therapy has been shown to be one of the more successful methods of reducing post-traumatic stress or anxiety and may be useful for these clients [48,49].