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Good Practice: Patient Safety Incidents

“The price of greatness is responsibility.”

I fervently believe that physiotherapists are great, but with greatness there is a heavy burden of responsibility, as Churchill describes. One such cost is a constant awareness of patient safety, fostering a safety culture in your workplace, and preventing patient safety incidents. By the time you finish reading this article I hope that I will have convinced you of the following:

  1. Patient safety incidents matter to patients and they matter to physiotherapists
  2. One patient safety incident or near miss is one too many.
  3. Patient safety incidents happen in ALL areas of physiotherapy practice. This is not someone else’s issue.
  4. Having a way to track and review patient safety incidents and modify unsafe or risky practices will improve patient safety, benefit the profession, and is a hallmark of quality care.

If I’m preaching to the converted, I hope that I can stoke the fire within you so that you remain vigilant and committed to reducing patient safety incidents in your practice environment.

Background

The World Health Organization has endorsed universal terminology to discuss adverse events, and although Adverse Event is the term that many, myself included, have historically used, the WHO advocates using the term Patient Safety Incident to describe “an event or circumstance which could have resulted, or did result in unnecessary harm to a patient.” This term is preferred over the terms adverse event, or critical incident. The term Near Miss is used to describe “an incident which did not reach the patient,” also known by some as a close call while the terms No Harm Incident and Harmful Incident describe incidents that do reach the patient.1

Why does universal terminology matter? Well for one thing, it ensures that there is consistent language to describe patient safety incidents, enabling comparisons over time between facilities, provinces and countries.2 This enables an analysis of gains made to reduce patient safety incidents and provides the opportunity to learn from the successes of others in reducing incidents and the harm associated with them. After all, when we are talking about patient safety incidents, we can’t lose sight of the fact that we are talking about harm done to somebody. Regardless of terminology, the most important thing to remember is that in a world where the only outcomes that matter are the ones that matter to the patient,3 negative outcomes matter the most.

It can happen to you

Having spent the bulk of my career working in acute care, I can understand why some physiotherapists may think that patient safety incidents are the problem of other disciplines or in other work settings. After all, in the hospital environment there’s a significant amount of attention given to medication and surgical errors, which could lead physiotherapists to believe that patient safety incidents only happen to nurses and doctors, not us. In private practice there’s talk of incidents relating to spinal manipulation4 and needling,2 but we tend to dismiss the incidents as being infrequent, and happening to other professions practicing the same techniques, not to physiotherapists.

The reality is that one high profile incident could radically change the faith that the public has in the physiotherapy profession. That’s without considering small incidents that don’t make headlines but do impact the public’s impression of the profession. Unexpected pain following treatment that leads a patient to discontinue treatment; a fall or near fall during a transfer that makes the patient fearful of future mobilization and leads to functional decline; the ventilator circuit that comes disconnected during suctioning leading to ventilator acquired pneumonia in the critically ill patient are all examples of incidents that can occur.

There is evidence to support the allegation that although patient safety incidents appear to occur infrequently, they are significantly underreported by health-care practitioners, with estimates of under reporting ranging from 50-96%.6 Faced with these issues, there is no room for complacency or a false sense of security.

Creating a shame-free, blame-free environment

Health-care providers can learn a great deal from other industries, where the concepts of safety incident and near miss reporting were pioneered. It has been estimated that near misses occur three to 300 times more frequently than adverse events.6 If attention is given to near miss events, there can be a significant increase in the amount of data available regarding factors that contribute to incidents, thereby adding significant value to quality improvement efforts. The success of near miss reporting systems hinges on the attitudes of health-care leaders, “an organization’s interpretation of near misses influences how it collects information related to safety, and thus its capacity to prevent the recurrence of undesirable events.”6 In other words: you can only change what you measure and you only measure what you think matters.

One of the key factors in working to reduce near misses is a shift from a culture of personal responsibility for errors to one that considers both individual and larger system issues as contributing to errors, near misses and incidents. Incorporating the concepts of a shame-free, blame-free reporting of near misses leads to increased reporting of incidents and better chances of correcting system issues. As Barach states “non-punitive, protected, voluntary incident reporting systems in high risk non-medical domains have grown to produce large amounts of essential process information unobtainable by other means,” there is no reason that the same could not be achieved in health care.

Although large organizations often have significant infrastructure invested towards near miss reporting systems, smaller organizations also need to invest time and effort to establish a system to track near misses and adverse events and work to correct the underlying factors that lead to the incidents.7 By engaging in a root cause analysis to systematically evaluate the sequence of events and identify the contributing factors that led to the incident, physiotherapists and their employers can make care safer for all patients.

Although serious or life threatening patient safety incidents are purportedly rare in physiotherapy clinical practice, they do still occur. The main difference between physiotherapy and other industries (aviation for example) is that when a plane crashes it gets significant media attention, when a patient suffers a pneumothorax from needling, falls during a treatment session, or receives a burn from a hot pack, it usually does not land on the front page of the newspaper.

A lack of media attention in no way negates the fact that the life of someone we were responsible for has been altered significantly and that’s no small matter.

The College of Physiotherapists of Alberta is committed to ensuring patient safety. In pursuit of this goal we have created the Patient Safety and Risk Management Practice Guideline to support physiotherapists’ understanding of these issues and engaged in other activities to support safe clinical practice in Alberta.

  1. World Health Organization, World Alliance for Safer Health Care. Classification for Patient Safety: Version 1.1. World Health Organization, 2009. Available at: http://www.who.int/patientsafety/implementation/taxonomy/icps_technical_report_en.pdf Accessed on: August 29, 2014.
  2. McDowell JM, Johnson GM, Hale L. Adverse reactions to acupuncture: Policy recommendations based on practitioner opinion in New Zealand. New Zealand Journal of Physiotherapy 2013; 41 (3): 94-101.
  3. Porter ME, Lee TH. The strategy that will fix health care. Harvard Business Review 2013; October: 50-70.
  4. Struewer J, Frangen TM, Ziring E, Hinterseher U, Kiriazidis I. Massive menatothorax after thoracic spinal manipulation for acute thoracolumbar pain. Orthopedic Reviews 2013; 5 (e27): 120-122.

Page updated: 20/04/2022