Stratagies to Reduce Medical Errors

Medical errors can happen in any field related to medicine however the consequences of medical errors are especially serious in the mental health care field. Many of the medical errors made in the mental health care sector are errors made while diagnosing and prescribing psychotic and mental help drugs and the aim of this course is to help mental health care professionals learn the causes of the medical error and learn how to avoid medical errors.

Medical errors are simple or complex errors made by medical health care professionals during the course of the day which can have serious consequences. These medical errors can cause severe damage to the patients depending on the type of error and are often caused by distractions, temporarily impaired judgment, lack of communication or poor communication and inadequate information related to the patient.

Medical errors can be classified under 2 main categories being acts of commission and acts of omission. Acts of commission are actions done that cause harm and acts of commissions are actions that one fails to do that causes harm. For instance an act of commission is giving wrong information to the patient. Not disclosing information to the patient regarding his problem would be considered an act of omission.

Acts of commission and acts of omission occur at micro and macro level. Macro level errors are made by agencies or organizations and micro level errors are made by individuals. Examples of macro acts of commission, micro acts of commission, macro acts of omission and micro acts of omission are mentioned below.

Macro acts of commission - Providing wrong information to the doctors regarding patient and mixing up patient data files.

Micro acts of commission – Providing the wrong information to patients, misdiagnosing the patient, prescribing the wrong drugs, breaching patient confidentiality and sexual misconduct.

Macro acts of omission – Failure to provide a safe environment to work in, failure to provide medical records of patients, failure to train medical professionals adequately, supervisory oversight, failure to provide a therapy room in which the therapist can work in and failure to conduct proper background checks of new medical professionals

Micro acts of omission – Failure to keep adequate records of patients, failure to report child abuse and failure to mention interactions of drugs.
Medication errors are acts of commission when the doctors prescribe the wrong drugs or the pharmacists give the wrong drugs. When the doctor does not provide information about drug interactions such an error is an act of omission.

An instance of a medical error made by human and machinery errors is listed below and note that this medical error could have been avoided if the health care professionals would have remained vigilant and changed the machines when required.

Ways Mental health Professionals are minimizing medical errors.
Health care organizations work to reduce medical errors by using technology, improving processes, zeroing in on errors that cause harm, and building a culture of safety. The following are important aspects in reducing medical errors in mental health care.

Competence
Therapists cannot practice outside of their scope of practice. This means that they must only practice in areas in which they have been trained.  Scope of practice is defined for the entire profession, whereas scope of competence is different for each individual therapist.

Client Rights
When counseling is initiated, and throughout the counseling process as necessary, therapists informs their clients of the purposes, goals, techniques, procedures, limitations, potential risks, and benefits of services to be performed, and other pertinent information. Therapists take steps to ensure that clients understand the implications of diagnosis, the intended use of tests and reports, fees, and billing arrangements. A therapist must disclose their fee prior to the beginning of the first session, preferably prior to the first session. A therapist working for an organization must disclose the name of the owner of any fictitious business name.

Clients have the right to expect confidentiality and to be provided with an explanation of its limitations, including supervision and/or treatment team professionals; to obtain clear information about their case records; to participate in the ongoing counseling plans; and to refuse any recommended services and be advised of the consequences of such refusal.  Therapists offer clients the freedom to choose whether to enter into a counseling relationship and to determine which professionals will provide counseling.

Restrictions that limit choices of clients are fully explained. When counseling minors or persons unable to give voluntary informed consent, therapists act in the clients best interests.

Confidentiality
Therapists respect their client’s right to privacy and avoid illegal and unwarranted disclosures of confidential information. The right to privacy may be waived by the client or his or her legally recognized representative. The general requirement that therapists keep information confidential does not apply when disclosure is required to prevent clear and imminent danger to the client or others or when legal requirements demand that confidential information be revealed. Therapists consult with other professionals when in doubt as to the validity of an exception.  When court ordered to release confidential information without the client’s permission, therapists request to the court that the disclosure not be required due to potential harm to the client or counseling relationship.
When circumstances require the disclosure of confidential information, only essential information is revealed. To the extent possible, clients are informed before confidential information is disclosed. When counseling is initiated and throughout the counseling process as necessary, therapists need to inform their clients of the limitations of confidentiality and identify foreseeable situations in which confidentiality must be breached.

Therapists make every effort to ensure that privacy and confidentiality of clients are maintained by subordinates including employees, supervisees, clerical assistants, and volunteers. If client treatment will involve a continued review by a treatment team, the client will be informed of the team’s existence and composition.

Minor or Incompetent Clients
When counseling clients who are minors or individuals who are unable to give informed consent voluntary, parents or guardians may be included in the counseling process if appropriate. Therapists act in the best interests of the clients and take care to safeguard their confidentiality.

Personal Needs and Values
In the counseling relationship, Therapists are aware of the intimacy and responsibilities in the counseling relationship, maintain respect for clients, and avoid actions that seek to meet their personal needs at the expense of clients. Therapists are aware of their own values, attitudes, beliefs, and behaviors and how these apply in a diverse society, and avoid imposing their values on clients.

Dual Relationships
Therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of clients. Therapists make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. Examples of such relationships include, but are not limited to, familial, social, financial, business, or close personal relationships with clients. When a dual relationship cannot be avoided, Therapists take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. Therapists do not accept superiors or subordinates with whom they have administrative, supervisory, or evaluative relationships as clients.

Sexual Intimacies with Clients
Therapists do not have any type of sexual intimacies with clients and do not counsel persons with whom they have had a sexual relationship

Multiple Clients
When therapists agree to provide counseling services to two or more persons who have a relationship, such as husband and wife, or parents and children, therapists clarify at the outset which person or persons are clients and the nature of the relationships they will have with each involved person. If it becomes apparent that therapists may be called upon to perform potentially conflicting roles, they clarify, adjust, or withdraw from roles appropriately.

Group Work
Therapists screen prospective group counseling/therapy participants. To the extent possible, therapists select members whose needs and goals are compatible with goals of the group, who will not impede the group process, and whose well-being will not be jeopardized by the group experience. In a group setting, therapists take reasonable precautions to protect clients from physical or psychological trauma.

Fees and Bartering
Therapists clearly explain to clients, prior to entering the counseling relationship, all financial arrangements related to professional services including the use of collection
agencies or legal measures for nonpayment. In establishing fees for professional counseling services, therapists consider the financial status of clients and locality. In the event that the established fee structure is inappropriate for a client, assistance is provided in attempting to find comparable services of acceptable cost.  Therapists ordinarily refrain from accepting goods or services from clients in return for counseling services because such arrangements create inherent potential for conflicts, exploitation, and distortion of the professional relationship. Therapists may participate in bartering only if the relationship is not exploitative, if the client requests it, if a clear written contract is established, and if such arrangements are an accepted practice among professionals in the community. However, bartering can be complicated and therefore may become unethical. 

Therapists contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return (pro bono).

Termination and Referral
Therapists do not abandon or neglect clients in counseling. Therapists assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, and following termination.  If therapists determine an inability to be of professional assistance to clients, they avoid entering or immediately terminate a counseling relationship. Therapists are knowledgeable about referral resources and suggest appropriate alternatives. If clients decline the suggested referral, Therapists should discontinue the relationship.  Therapists terminate a counseling relationship (securing client agreement when possible), when it is reasonably clear that the client is no longer benefiting, when services are no longer required, when counseling no longer serves the clients needs or interests, when clients do not pay fees charged, or when agency or institution limits do not allow provision of further counseling services.

Professional Responsibility
Therapists have a responsibility to read, understand, and follow the Code of Ethics and the Standards of Practice.

Professional Competence
Therapists practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Therapists will demonstrate a commitment to gain knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse client population.  Therapists practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, Therapists take steps to ensure the competence of their work and to protect others from possible harm.  Therapists accept employment only for positions for which they are qualified by education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Therapists hire for professional counseling positions only individuals who are qualified and competent.  Therapists continually monitor their effectiveness as professionals and take steps to improve when necessary. Therapists in private practice take reasonable steps to seek out peer supervision to evaluate their effectiveness as therapists. Therapists take reasonable steps to consult with other therapists or related professionals when they have questions regarding their ethical obligations or professional practice.

Therapists recognize the need for continuing education to maintain a reasonable level of awareness of current scientific and professional information. They take steps to maintain competence in the skills they use, are open to new interventions, and keep current with the diverse populations that they work with. Therapists refrain from offering or accepting professional services when their physical, mental, or emotional problems are likely to harm a client or others. They are alert to the signs of impairment, seek assistance for problems, and, if necessary, limit, suspend, or terminate their professional responsibilities.

Advertising and Soliciting Clients
There are no restrictions on advertising by therapists except those that can be specifically justified to protect the public from deceptive practices. Therapists advertise or represent their services to the public by identifying their credentials in an accurate manner that is not false, misleading, deceptive, or fraudulent. Therapists may only advertise the highest degree earned which is in counseling or a closely related field from a college or university that was accredited when the degree was awarded. 

Therapists who develop products related to their profession or conduct workshops or training events ensure that the  advertisements concerning these products or events are accurate and disclose adequate information for consumers to make informed choices.  Therapists do not use counseling, teaching, training, or supervisory relationships to promote their products or training events in a manner that is deceptive or would exert undue influence on individuals who may be vulnerable. Therapists may utilize textbooks they have authored for instruction purposes.

Credentials
Therapists claim or imply only professional credentials possessed and are responsible for correcting any known misrepresentations of their credentials by others. Professional credentials include graduate degrees in counseling or closely related mental health fields, accreditation of graduate programs, national voluntary certifications, government-issued certifications or licenses, or any other credential that might indicate to the public specialized knowledge or expertise in counseling.  Therapists follow the guidelines for use of credentials that have been established by the entities that issue the credentials. Therapists do not attribute more to their credentials than the credentials represent, and do not imply that other therapists are not qualified because they do not possess certain credentials. Therapists who hold a master's degree in counseling or a closely related mental health field, but hold a doctoral degree from other than counseling or a closely related field, can not use the title "Dr." in their practices and do not announce to the public in relation to their practice or status as a therapist that they hold a doctorate.

Public Responsibility
Therapists do not discriminate against clients, students, or supervisees in a manner that has a negative impact based on their age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, or socioeconomic status, or for any other reason. Therapists do not engage in sexual harassment. Sexual harassment is defined as sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual in nature, that occurs in connection with professional activities or roles, and that either is unwelcome, is offensive, or creates a hostile workplace environment, and therapists know or are told this; or is sufficiently severe or intense to be perceived as harassment to a reasonable person in the context. Sexual harassment can consist of a single intense or severe act or multiple persistent or pervasive acts.  Therapists are accurate, honest, and unbiased in reporting their professional activities and judgments to appropriate third parties including courts, health insurance companies, those who are the recipients of evaluation reports, and others.  When Therapists provide advice or comment by means of public lectures, demonstrations, radio or television programs, prerecorded tapes, printed articles,
mailed material, or other media, they take reasonable precautions to ensure that:  the statements are based on appropriate professional counseling literature and practice; the statements are otherwise consistent with the Code of Ethics and the Standards of Practice; and the recipients of the information are not encouraged to infer that a professional counseling relationship has been established.  Therapists do not use their professional positions to seek or receive unjustified personal gains, sexual favors, unfair advantage, or unearned goods or services.

Responsibility to Other Professionals
Therapists are respectful of approaches to professional counseling that differ from their own. Therapists know and take into account the traditions and practices of other professional groups with which they work.  When making personal statements in a public context, Therapists clarify that they are speaking from their personal perspectives and that they are not speaking on behalf of all therapists or the profession.  When Therapists learn that their clients are in a professional relationship with another mental health professional, they request release from clients to inform the other professionals and strive to establish positive and collaborative professional relationships.

Diagnosing suicidal or homicidal cases and reporting them when needed
Certain boards such as the psychology board of Florida find medical errors such as inadequate assessment of suicidal and homicidal so important that they have included them in their medical errors training and require each and every practitioner to be thorough with such errors in order to avoid them. In order to avoid such drastic medical errors it is important for the psychologist to diagnose the patient, prescribe the required medication and report any suspected threats to the victim or others.

In order to properly evaluate suicidal or homicidal cases the mental health care professional has to evaluate the person’s case history and document all interventions and consultation when necessary. After the mental health care professional has appropriately judged the situation with another mental health care professional the next recommended step is to create and follow a clear protocol regarding the plan of action and how the mental health care professional can warn and help the patient.

Tarasoff v. Regents
The case of Tarasoff v. Regents of California (1976) was an important case in the history of medical changes and the Supreme Court of California declared that it is every mental health care professional’s duty to warn people if any patient has the potential to warn them with bodily harm. The case involved a patient who informed a clinician working in a University that he was going to kill his girlfriend. The clinician informed the university police of the situation but failed to warn the potential victim of the situation.

 The Baker Act
The Baker Act is an important act that helps the mental health care professional fulfill his “duty to protect” patients and citizens from any known harm. This act is a legal procedure that allows medical health care professionals to conduct involuntary examinations on people who are deemed dangerous to themselves or others. The criteria for carrying out the Baker act are based on two rules that are listed below.

• The person in question has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination
• The person is not competent enough to determine for himself if he requires an examination and without treatment.

The Baker act is valid for individuals if the person in both the scenarios can suffer from neglect out of no medications and improper treatment and can then be a threat to himself or others. 

Mandatory Abuse Laws
The General Protection for Children Act states that all children need to be protected and reporting of any child abuse, abandonment, or neglect and mandatory reports of death to the central abuse hotline is mandatory. The Adult Protective Services Act states that neglect or exploitation of vulnerable adults as well as reports of death of the elderly is mandatory for all mental health care professionals.
It is crucial for medical health professionals to report any kind of abuse or neglect for both children and elderly as soon as they identify it since the person being abused can be at serious risk if the matter is not reported at the earliest. It is often recommended to report abuse of any kind when the health care professional has a doubt that the person may be inflicted in any way. The reports can either be called in or faxed and emailed depending on the mental health care professional but following the protocol of reporting in mandatory.

Ways to avoid medical errors at macro levels
Communicating concerns to the organization is the best way to prevent errors at a macro level. If the mental health care professional requires additional help, a better environment to work in or better tools and equipment to work with he should contact the organization to ensure that these factors do not get in his way of work and create a medical error.

Avoiding medical errors through full disclosure
Another factor that can help mental health professionals prevent medical errors is full disclosure of the client’s data. In order for the counselor to diagnose the problem effectively he must know what exactly is happening to the client and what medications and therapies the client has undergone. Full disclosure is very important for mental health care professionals since certain mental conditions cannot be treated unless the patient provides all the information to the mental health care professional.

It is crucial that the doctor abides the patient confidentiality laws and does not give out the information in written, electronic or spoken form unless the patient is a potential threat to himself or others.

Other limitations include reporting of abuse, Duty to warn and duty to protect, Marriage and family therapy, Group counseling, HIV patients, Minors’ records, Health plans information gathering, Supervision and Multidisciplinary teams.

In family, marriage and group therapy it is the doctor’s duty to protect the confidentiality of the patients however at times patients tend to give out information to spouses and other group members.

In the interest of safeguarding public health HIV patients are required to report their HIV status to the board of health and medical doctors. Facilities that test for HIV and help HIV patients are very thorough about the need to comply with the law.

Asking other medical health care professionals for advice does not breach the patient’s confidentiality law as long as the information is used to help the patient. Some hospitals require doctors who deal in delicate fields such as mental health care professionals to share information with supervisors or experienced doctors in order to avoid medical errors.

Breach of Confidentiality

According to state law (Ch 90.503) confidentiality is as follows:

• This relationship is established once services, psychotherapy, counseling, assessment or treatment are rendered.
• A contract, scheduling of appointments, or payment of a fee are not necessary conditions to establish that a relationship exists.

This relationship between the mental health care professional and patient 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.

If the limitations of confidentiality do not apply on a patient’s case then the therapist or mental health care professional is not allowed to disclose the patient’s personal information to a third party without the patient’s consent or a court order. Patient confidentiality is very critical to help a patient since most patients will only opt for a full disclosure if they are sure that the information provided is not disclosed by the therapist to anyone else. Full disclosure enables a mental health care professional to evaluate, diagnose and treat the condition better since the mental health care professional has all the required data. Maintaining patient confidentiality is a legal and ethical duty of every health care professional. Breach of confidentiality through disclosure can happen through oral, electronic and written means. Breach of confidentiality is an act of commission and is a medical error.

Medical and humane error – Sexual Misconduct

According to the Disciplinary Guideline code:

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). (64b4-10.002)

Engaging in sexual activity with a patient who is not competent enough to make a decision is considered as sexual misconduct and sexual harassment and serious action is taken against the health care professional for committing such a medical error.

Computer Technology

In today’s society many people are reaching out to online therapy.  Here are some guidelines to ensure privacy, informed consent and information sharing.  Additionally with health insurance forms and therapy notes therapists utilize the internet and must ensure clients privacy.

When computer applications are used in counseling services, therapists ensure that:  the client is intellectually, emotionally, and physically capable of using the computer application; the computer application is appropriate for the needs of the client; the client understands the purpose and operation of the computer applications; and a follow-up of client use of a computer application is provided to correct possible misconceptions, discover inappropriate use, and assess subsequent needs.

Privacy Information
Professional Therapists ensure that clients are provided sufficient information to adequately address and explain the limitations of computer technology in the counseling process in general and the difficulties of ensuring complete client confidentiality of information transmitted through electronic communications over
the Internet through on-line counseling.

Secured Sites
To avoid the risk of potential breaches of confidentiality, professional therapists provide one-on-one on-line counseling only through "secure" Web sites or e-mail communications applications which use appropriate encryption technology designed to protect the transmission of confidential information from access by unauthorized third parties.

Non-Secured Sites
To avoid the risk of potential breaches of confidentiality, professional therapists provide only general information from "non-secure" Web sites or e-mail communications applications.

General Information
Professional therapists may provide general information from either "secure" or "non-secure" Web sites, or through e-mail communications. General information includes non-client-specific, topical information on matters of general interest to the therapist’s clients as a whole, third-party resource and referral information, addresses and phone numbers, and the like. Additionally, therapists using either "secure" or "non-secure" Web sites may provide "hot links" to third-party Web sites such as licensure boards, certification bodies, and other resource information providers. Therapists investigate and continually update the content, accuracy and appropriateness for the client of material contained in any "hot links" to third-party Web sites.

Limits of Confidentiality
Therapists inform clients of the limitations of confidentiality and identify foreseeable situations in which confidentiality must be breached in light of the law in both the state in which the client is located and the state in which the therapist is licensed.  Additionally, you need to see if you are legally allowed to practice therapy on-line with an out of state client. You should check with your state licensing board.

Therapists provide a readily visible notice that information transmitted over a Web site or e-mail server may not be secure; whether or not the therapist’s site is secure;  whether the information transmitted between the therapist and the client during online counseling will be encrypted; and whether the client will need special software to access and transmit confidential information and, if so, whether the therapist provides the software as part of the on-line counseling services. The notice should be viewable from all Web site and e-mail locations from which the client may send information.

Therapists provide a readily visible notice advising clients of the identities of all therapists who will have access to the information transmitted by the client and, in the event that more than one therapist has access to the Web site or e-mail system, the manner, if any, in which the client may direct information to a particular therapist. Therapists inform clients if any or all of the sessions are supervised.

Clients are also informed if and how the supervisor preserves session transcripts.  Therapists provide background information on all therapists and supervisors with access to the on-line communications, including education, licensing and certification, and practice area information.  Therapists identify clients, verify identities of clients, and obtain alternative methods of contacting clients in emergency situations.  Therapists require clients to execute client waiver agreements stating that the client acknowledges the limitations inherent in ensuring client confidentiality of information transmitted through on-line counseling and agrees to waive the client's privilege of confidentiality with respect to any confidential information transmitted through online counseling that may be accessed by any third party without authorization of the client and despite the reasonable efforts of the therapist to arrange a secure on-line environment. Therapists refer clients to more traditional methods of counseling and do not provide on-line counseling services if the client is unable or unwilling to consent to the client waiver.

Records of Electronic Communications
Therapists maintain appropriate procedures for ensuring the safety and confidentiality of client information acquired through electronic communications, including but not limited to encryption software; proprietary on-site file servers with fire walls; saving on-line or e-mail communications to the hard drive or file server computer systems; creating regular tape or diskette back-up copies; creating hardcopies of all electronic communications; and the like. Clients are informed about the length of time for, and method of, preserving session transcripts. Therapists warn clients of the possibility or frequency of technology failures and time delays in transmitting and receiving information.

Electronic Transfer of Client Information
Therapists electronically transfer client confidential information to authorized third-party recipients only when both the therapist and the authorized recipient have secure transfer and acceptance communication capabilities, the recipient is able to effectively protect the confidentiality of the client confidential information to be transferred; and the informed written consent of the client, acknowledging the limits of confidentiality, has been obtained.

Boundaries of Competence
Therapists provide on-line counseling services only in practice areas within their expertise and do not provide on-line counseling services to clients located in states in which therapists are not licensed, in which your license is not acknowledged and/or your license is only valid for the state that you are licensed in. You need to check with your state board of licensing to find your limitation regarding

Conclusion

• Medical errors are simple or complex errors made by medical health care professionals during the course of the day which can have serious consequences. The medical errors can be acts of commission or acts of omission and it is important finding the cause of the error can help in reducing and eliminating similar errors.
• Errors at the macro level can be solved by communicating concerns to the hospital or organization and by asking the organization to adequately train the medical health care professionals or use software that eliminate medical errors. Errors at the micro level can be avoided by providing all the required information to patients, ensuring that the right drug is provided to the patient, ensuring that the mental health care professional keeps himself updated about all the latest information on drugs and staying alert while interacting with a patient. Following patient confidentiality laws and acquiring full disclosure while dealing with the patients is another way mental health care professionals can reduce medical errors.
• Inadequate assessment of suicidal or homicidal patients is a serious medical error and The Baker Act can be followed to ensure that the patient does not harm himself or others.
• Reporting of child abuse and elderly abuse is mandatory and failure to do so is considered a serious medical error.
• Pharmacists can reduce medical errors by double checking the prescription before giving the patient the prescribed drug. Steps taken by the FDA to reduce and eliminate medical errors include the bar code label rule, naming drugs appropriately in order to avoid confusion and drug labeling.

Cultural Issues in Counseling
Cultural safety is an emerging area of focal interest in patient safety programming and policy.

Genuine cross-cultural competency in health requires the effective integration of traditional and contemporary knowledge and practices on both an individual and an organization-wide
basis. In a multi-cultural setting, both quality of care and patient safety are optimized by moving beyond cultural competence.

Cross-Cultural Client Safety Analytical Framework
Cultural safety is defined as the safe practice and successful delivery of health care services across the barriers to understanding and identifying client needs. It includes
overcoming the obstacles to implementing prescribed remedial or supportive actions.

We have identified numerous core risk factors and potential mitigation strategies. These factors are summarized below. The analytical framework categorizations extend beyond the patient
safety programming already in place related to infection control, medication errors, adverse events, and other typical health service safety issues.

These include the issues of understanding stemming from language and world-view differences, and incorporate other important potential root causes related to client
safety and risk.
www.slmhc.on.ca

1. Linguistic
potential for misunderstanding descriptions of the presenting symptoms, etc. and/or the prescribed course of diagnostic or therapeutic intervention – terminology limitations in
a language, idiom and vernacular, and non-verbal communications may also be critical
factors.

2. Cultural
potential for misunderstanding the cultural context of the presenting pathology and/or the ability to successfully implement a prescribed course of action in the face of contradictory world views, value sets, norms and morals

3. Medical literacy
varying medical literacy rates among different populations, especially where native languages do not include medical or related terminology, and where cultural or ethnic variations in access and use of medical/health services impact the effectiveness and outcomes of those services in reaching diverse populations, or ability to navigate the system because of a lack of familiarity

4. Program or practice
conventional services/practices contrasted with traditional practices specific to the culture(s) in question

5. Context or structural
potential for misunderstanding or mishap due to cultural habitats and (lack of) knowledge associated with them

6. Systemic
disconnects between mainstream systems and specific population providers including territoriality, overlaps, gaps, differing approaches, jurisdictional differences, etc. –often relates to access and availability

7. Genetics
failure to know of or take into account inherent issues in a population

8. Respecting Diversity
Therapists do not condone or engage in discrimination based on age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, marital status, or socioeconomic status. Therapists will actively attempt to understand the diverse cultural backgrounds of the clients with whom they work. This includes, but is not limited to; learning how the Therapists own cultural/ethnic/racial identity impacts her or his values and beliefs about the counseling process.

Here is the Psychotherapist-Patient privilege code for Florida
Title VII   EVIDENCE
Chapter 90   EVIDENCE CODE
90.503  Psychotherapist-patient privilege.--
(1)  For purposes of this section:
(a)  A "psychotherapist" is:
1.  A person authorized to practice medicine in any state or nation, or reasonably believed by the patient so to be, who is engaged in the diagnosis or treatment of a mental or emotional condition, including alcoholism and other drug addiction;
2.  A person licensed or certified as a psychologist under the laws of any state or nation, who is engaged primarily in the diagnosis or treatment of a mental or emotional condition, including alcoholism and other drug addiction;
3.  A person licensed or certified as a clinical social worker, marriage and family therapist, or mental health counselor under the laws of this state, who is engaged primarily in the diagnosis or treatment of a mental or emotional condition, including alcoholism and other drug addiction;
4.  Treatment personnel of facilities licensed by the state pursuant to chapter 394, chapter 395, or chapter 397, of facilities designated by the Department of Children and Family Services pursuant to chapter 394 as treatment facilities, or of facilities defined as community mental health centers pursuant to s. 394.907(1), who are engaged primarily in the diagnosis or treatment of a mental or emotional condition, including alcoholism and other drug addiction; or
5.  An advanced registered nurse practitioner certified under s. 464.012, whose primary scope of practice is the diagnosis or treatment of mental or emotional conditions, including chemical abuse, and limited only to actions performed in accordance with part I of chapter 464.
(b)  A "patient" is a person who consults, or is interviewed by, a psychotherapist for purposes of diagnosis or treatment of a mental or emotional condition, including alcoholism and other drug addiction.
(c)  A communication between psychotherapist and patient is "confidential" if it is not intended to be disclosed to third persons other than:
1.  Those persons present to further the interest of the patient in the consultation, examination, or interview.
2.  Those persons necessary for the transmission of the communication.
3.  Those persons who are participating in the diagnosis and treatment under the direction of the psychotherapist.
(2)  A patient has a privilege to refuse to disclose, and to prevent any other person from disclosing, confidential communications or records made for the purpose of diagnosis or treatment of the patient's mental or emotional condition, including alcoholism and other drug addiction, between the patient and the psychotherapist, or persons who are participating in the diagnosis or treatment under the direction of the psychotherapist. This privilege includes any diagnosis made, and advice given, by the psychotherapist in the course of that relationship.
(3)  The privilege may be claimed by:
(a)  The patient or the patient's attorney on the patient's behalf.
(b)  A guardian or conservator of the patient.
(c)  The personal representative of a deceased patient.
(d)  The psychotherapist, but only on behalf of the patient. The authority of a psychotherapist to claim the privilege is presumed in the absence of evidence to the contrary.
(4)  There is no privilege under this section:
(a)  For communications relevant to an issue in proceedings to compel hospitalization of a patient for mental illness, if the psychotherapist in the course of diagnosis or treatment has reasonable cause to believe the patient is in need of hospitalization.
(b)  For communications made in the course of a court-ordered examination of the mental or emotional condition of the patient.
(c)  For communications relevant to an issue of the mental or emotional condition of the patient in any proceeding in which the patient relies upon the condition as an element of his or her claim or defense or, after the patient's death, in any proceeding in which any party relies upon the condition as an element of the party's claim or defense.
History.--s. 1, ch. 76-237; s. 1, ch. 77-77; s. 22, ch. 78-361; s. 1, ch. 78-379; s. 40, ch. 90-347; s. 1, ch. 92-57; s. 19, ch. 93-39; s. 475, ch. 95-147; s. 28, ch. 99-2; s. 5, ch. 99-8; s. 1, ch. 2006-204.
Last modified: November 21, 2006