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Conduct Matters: Formal Caution Issued After Hot Pack Burn Investigated (Case Study)

The Complaint

A patient attended their third physiotherapy session for treatment of bilateral Golfer’s Elbow. Part of the treatment consisted of the application of Transcutaneous Electrical Nerve Stimulation (TNS) and hot packs. Several hours later, the patient discovered that a blister burst on their elbow, only then realizing they had suffered a burn. The patient returned to the clinic three days later, showing the burn to the physiotherapist. The patient stated that no concern was shown for the burn, adding that the physiotherapist commented, “your skin is very sensitive”. The patient decided to seek treatment of a physician six days after being burned due to swollen lymph nodes. A topical antibiotic was prescribed. Thirteen days after the burn the patient stated that the infection had gone down but was still present. At this point the patient decided to submit a formal complaint to the college.

The Investigation

A photo provided by the patient, dated one week following the incident, showed a wound the size of a toonie on the lateral aspect of the elbow between the lateral aspect of the [epicondyle and the olecranon process]. There was a moderate area of erythema surrounding the wound approximately four inches in diameter. The burn appeared to be below the dermis.

The physiotherapist confirmed that the clinic standard construction for a hot pack consisted of a hot pack cover with four additional layers of towel. Administration staff are trained to construct the hot packs for patients, but it was only the physiotherapist who checks and applies the hot packs, which is what took place in this instance. The patient stated that they had some pain when the hot pack when applied but they did not say anything to the physiotherapist at the time of the treatment.

The physiotherapist stated that the temperature of the hydrocollator was monitored regularly but documentation regarding the results of the monitoring was not kept. The physiotherapist’s submissions were inconsistent as to how frequent the hydrocollator temperature was monitored: from twice daily to weekly. There were no written policies and procedures regarding hot pack construction, or hydrocollator monitoring.

The patient stated in both in a written submission and an interview that when they showed the injury to the physiotherapist, there was no apology given for the injury and there was little recognition that a burn had occurred. The physiotherapist was consistent that an apology was given to the patient during the last two scheduled treatments.

The treatment notes stated that the burn occurred on the medial aspect of the elbow, while the photo showed that the burn occurred on the lateral aspect of the elbow. When the investigator showed the photo to the physiotherapist, the physiotherapist confirmed that the photo of the burn was as they remembered it. The physiotherapist did not provide a reasonable answer as to why they had previously and consistently documented that the burn occurred to the medial aspect of the elbow.


The evidence supports that the complainant clearly suffered a burn, likely a second-degree burn, to their right elbow as a result of the physiotherapy treatment. This point was undisputed. The cause of the injury was a thermal burn from the hot packs, not an electrical burn from the TNS. No studies were found that support burns resulting from TNS electrical stimulation. The burn occurred on the lateral aspect of the elbow, while the electrical current was provided to the medial aspect of the elbow.

The hot pack construction was considered to be within the norm. Having a nonprofessional staff prepare modalities for patient application is not outside “normal” clinical practices; however, there should be standardized written training procedures and modality procedures in place for each patient care activity nonprofessional staff undertakes.

Potential causes of a thermal burn could be one or a combination of the following:

  • The hot pack was not constructed as per standard procedure.
  • The hot pack was applied with the hot pack cover in contact with the patient without the extra toweling.
  • The patient may have had some type of lotion on the skin that increased the thermal effect of the hot pack.
The Apology

Other than the two individuals’ accounts of the interaction there was no evidence to support or refute either account. The patient was clear in their complaint that they did not feel that the physiotherapist fully appreciated the severity of the injury and that patient felt that the physiotherapist failed to act appropriately. The Risk Management Standard of Practice performance expectation is that the physiotherapist recognizes the occurrence of near misses and adverse events (e.g., hot pack burns, falls) and responds immediately to minimize the impact on the client.

Equipment Maintenance

Documentation of equipment maintenance history is required by the Documentation and Record Keeping Standard. Although the Standard does not specify how frequently the inspections and calibrations must occur, the expectation states that the physiotherapist verifies and documents that the equipment used in physiotherapy practice is routinely inspected and calibrated on a regular basis according to applicable legislation and manufacturers’ recommendations.

The Outcome

The Complaints Director decided that there was insufficient evidence of unprofessional conduct to support referral of this matter to a hearing; however, the complaints director provided the member with a formal caution, stating that injury to a patient as a result of physiotherapy care is extremely serious. It is the professional responsibility of every regulated physiotherapist to ensure that every available precaution is undertaken to protect patients from possible injury. This matter will be kept on the member’s permanent College file and considered, should any future complaints of a similar nature be received.

The Complaints Director strongly advised the physiotherapist to complete and implement the following recommendations specific to the complaint raised by the complainant.

  • Review and clearly understand the parameters of all electrotherapy equipment used in practice.
  • Develop and implement written policies regarding all clinic practices, at the minimum, for equipment maintenance, nonprofessional staff training, and all patient care activities for which nonprofessional staff may be involved.
  • Engage an independent agency to perform regular equipment maintenance checks and calibration services.
  • Ensure that each patient clearly understands when, why and how to call for assistance.
  • Ensure that treatment notes are an accurate reflection of the presenting condition and the care provided (medial vs lateral).
  • Review, in detail, the following College of Physiotherapists of Alberta, Standards of Practice:

Page updated: 09/09/2022