Even if you followed all the best practices related to patient care, sometimes patient safety incidents still occur. A patient can have a heart attack, a family member waiting to pick up your patient can faint in the waiting room, or a patient can trip getting off the exercise bike. Physiotherapists would typically all love to go through their careers without being involved in a patient safety incident, but odds are that one or two will happen. That said, we do know that the time you spend evaluating near misses, proactively working to prevent adverse events and preparing to respond to a patient safety incident reduces the risk of your patient having a negative outcome.
This article will highlight the new Standard of Practice – Risk Management and Safety by following Fernando’s journey through his own patient safety incident. The goal of this article is to highlight the expectations found in the Standard and other CPTA safety and risk management resources.
What does the new Standard say?
It states that:
“Clients can expect to be safe in the care of the physiotherapist and in the practice environment, and that any patient safety incidents will be appropriately addressed and disclosed promptly and transparently.”
The physiotherapist:
- Recognizes the occurrence of patient safety incidents and near misses.
- Responds immediately to patient safety incidents to minimize the impact on the client.
- Documents patient safety incidents and near misses in the client’s treatment record and completes reports appropriate to the practice setting in accordance with employer policies and procedures.
- Contributes to the collection of data to identify, manage, remediate, and prevent potential risks and patient safety incidents relevant to the practice setting and population served.
- Discloses details of patient safety incidents related to physiotherapy services to the client and appropriate parties promptly and transparently.
Note: You may have noticed the College uses the word “client” in almost all of our communications and in Standards of Practice. One exception is in reference to “patient safety incidents.” Consistent language is important for reporting and monitoring negative outcomes and incidents in health-care settings. The phrase “patient safety incident” is used by Healthcare Excellence Canada and has been adopted by the College to facilitate consistency and support reporting and monitoring.
Fernando works at a long-term care facility. He came back on shift after a few days off and checked up on his patients. It was documented that Mr. Mota had recently changed medications and appeared a bit “off” since the change.
Fernando did the right thing and checked in with both the chart record and other staff members to see what had been happening while he was away. Documentation should provide Fernando with an accurate representation of what happened on his days off, but it is also important to talk to staff face-to-face to get a full picture of the concerns expressed regarding Mr. Mota.
Fernando reassessed Mr. Mota’s ability to independently transfer and walk due to the noted changes in the chart. He talked to the nursing staff and health-care aides who confirmed there have been some differences in his energy levels and ability to stay engaged in group settings. Mr. Mota has a doctor’s appointment coming up to review his medication.
Due to the changes in Mr. Mota’s condition, Fernando brought a transfer belt and one of the health-care aides to help him assess Mr. Mota. During the assessment Mr. Mota got lightheaded when he stood up. Despite using a transfer belt and having the health-care aide there to assist him, Mr. Mota’s lightheadedness caused him to have a fall. Fernando was able to lower Mr. Mota to the floor with the transfer belt but Mr. Mota hit his head on the side table on the way down. Fernando checked for other injuries and then called for help.
After Mr. Mota was evaluated by the staff he was returned to his bed. Fernando documented the incident in the chart and completed an incident report as per the facility’s policies and procedure manual.
Despite being aware of the changes to Mr. Mota’s health and adjusting his treatment to try to address those changes, a patient safety incident occurred. As this scenario shows, it is important to not only have a patient safety incident management plan but to also review and practice them so that you can respond correctly when needed. Failure to do so can put the patient at an increased risk of a poorer outcome.
Side Note: Practice sites should also have critical event management plans that are specific to the foreseeable risks within the practice site. Plans should be regularly reviewed and practiced. Examples of these would be fire or evacuation plans and drills to help ensure staff understand their roles and responsibilities in emergency situations.
It's great that Fernando completed the documentation, but he could also improve communication on this issue by discussing the incident with management and completing a debrief with other staff.
The College’s Patient Safety and Risk Management Guide provides information about patient safety and mitigating risks related to practice. The Guide can walk you through how to review specific risks and harms related to your practice, how to develop a framework to classify and track harms, and how to develop Patient Safety Incident Plans relevant to your practice.
The following day Fernando reached out to Mr. Mota’s son to discuss what occurred and they set up a meeting with Fernando, Mr. Mota and Mr. Mota’s son to discuss things further.
Disclosure is an integral part of dealing with a patient safety incident or a near miss. The Health Quality Council of Alberta has published a webpage and resources dedicated to disclosure and provided a webinar for CPTA registrants on Responding When Things Don’t Go as Planned. The CPTA has also published a How To Manual on Apologies that provides guidance on how to disclose harm or near misses, and how and when to apologize.
Patient Safety Incidents Actionable Items
- Review policies and procedures relating to patient safety and patient safety incidents.
- Review management plans for all relevant risks in your practice setting. These should include general evacuation procedures for fire/flood as well as specific risks related to physiotherapy services such as dry needling, spinal manipulation, internal pelvic health exams, and other treatments.
- Practice patient safety incident responses and evacuation drills.
- Document and discuss incidents and near misses so that your entire practice site is aware of them.
- Review polices and procedures related to disclosure of harm and near misses to ensure alignment with the Health Quality Council of Alberta.
