I was covering for another therapist over the weekend. I was instructed to review hip precautions, proper gait, and total hip replacement exercises with the patient in room 110. It was a very busy day, so I just went with the notes left by her primary therapist and did not review her chart. I went to the room and found the patient to be very cooperative. I reviewed hip precautions and then went over proper gait with a walker and total hip replacement exercises without violating the standard hip precautions for her surgery. As I instructed her, I realized that she had cognitive issues, such as difficulty following three-step directions and decreased auditory functioning, so I made sure to simplify the instructions and posted handouts with pictures as a reminder. I transferred her back to bed, and she asked for a glass of water.

Humans drive healthcare systems, and humans make mistakes. Even the most well-educated, well-trained, and dedicated professionals make errors. The Institute of Medicine defines medical 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 Whatever the mechanism, the consequences of an error can be significant. Hospital errors are the eighth leading cause of death in the United States, surpassing deaths from motor vehicle accidents or breast cancer.¹ While the nature of errors in physical therapy practice is less likely to lead to death, physical or psychological harm may occur, and all instances of this should be considered significant. Errors diminish client confidence in the therapist and, less significant to the patient though no less important, physical therapy errors undermine the credibility of the profession.

Types and Causes of Errors

In 2001 and 2002, a research team from Creighton University School of Pharmacy and Health Professions conducted a grant-funded national survey to examine occupational therapy practice errors in physical rehabilitation and geriatrics.² They examined the types of errors, causes of errors, and impact of errors on occupational therapy practice. The vast majority of errors occurred during interventions. These errors were further divided into five subcategories:

1. Communication between providers

2. Education provided to patients, caregivers, and other providers: For example, a busy therapist did not provide adequate instruction to a nursing aide regarding splint application and removal. The aide affixed the straps inappropriately, resulting in skin breakdown.

3. Documentation of interventions: This may include recording the wrong billing code or providing insufficient documentation for payment to be rendered.

4. Supervision provided by therapists to patients, students, other providers: For example, a therapist walks away from an impulsive patient sitting on a mat; the patient tries to stand up and falls.

5. Treatment provided by therapists during interventions: For example, leaving a hot pack on an insensate hand too long, resulting in a small burn.

In the case example, several of these error types are outlined. Communication between the primary and covering therapist was inadequate. The primary therapist did not leave enough information about the intended patient for the covering therapist to differentiate her from her roommate. Clearly, a treatment error was made, when the therapist delivered care to the wrong patient. Also in this category, the therapist failed to monitor the patient’s vitals, as was ordered by the physician. Of course, the therapist did not know this was necessary, as she did not conduct a comprehensive, or even cursory, chart review — another communication error. While the patient incurred no direct harm, it could be considered a "near miss," which can also serve as a learning experience.

Per the Creighton University researchers’ report,² nearly 75% of the 245 respondents identified misjudgment as the primary cause of practice errors. In the vast majority of reported errors, therapists simply misjudged the situation; therapists made errant assumptions that led to undesired outcomes. Specific examples of misjudgments pertaining to weight bearing status, balance, treatment tolerance, and patient comprehension were cited.³ Inadequate preparation (46%) and lack of experience (34%) were the second and third most common causes of errors. Other reported causes of errors included lack of assertiveness, overaggressive intervention, poor listening skills, insufficient time to work with patients, staff shortage, unclear documentation, insufficient communication, patient fatigue, patient noncompliance, and patient had limited communication.

The errors committed in the case example are likely a factor of inadequate preparation. The covering therapist did not have enough information about the intended patient, nor did she conduct a chart review or confirm the patient’s identity at the beginning of the session. Judgment is also factor here, and overload/time restraint likely played a role. Of course, practice errors are complicated and often a constellation of factors contributes to a single event.

Impact of Errors

Perhaps more important than the cause of an error is the impact of an error. The Creighton University researchers5 found that nearly half of the reported errors resulted in emotional distress for the patient, and almost 90% resulted in the therapist feeling remorseful, angry at self and guilty. Overwhelmingly, respondents reported that the errors caused them to be more vigilant in their practice. Ninety-two percent of respondents reported reflecting on the errors and related circumstances. Eighty-three percent of the respondents reported that they paid more attention to particular practice situations following the errors, and 68% reported that they changed their practice approach following the incident.

Surely, the therapist in the case example felt remorseful because she treated the wrong patient, and likely she felt frustrated that this error complicated her day. Luckily, in this example, the patient impact was minimal; but given her medical instability, it could have been much worse. Based on the evidence, it is fair to assume that the therapist will be more vigilant when covering unfamiliar patients and more diligent in her chart reviews.

Ironically, findings seem to suggest that making errors has a relatively positive impact on a therapist’s practice. If a therapist is able to demonstrate meaningful change in response to an error, then it’s possible that outcomes will increase and patient safety will improve overall. Even better is when this experience is shared with a group of therapists and policy and procedure changes are enacted in response to significant events. Therapists refine their clinical reasoning and skills through experience and practice. Creating an open environment that encourages idea sharing and collective problem solving allows others to learn from one therapist’s mistakes and hopefully leads to fewer errors. An atmosphere of openness should also include no threats of punishment by organizations. Regular program review and outcomes evaluation is strongly associated with improved patient safety.⁵ An institution’s accountability procedures are key to managing errors. First, the therapist has to be honest and forthright with all parties. Second, established procedures help to ensure systematic error review and program modification, if necessary. Accountability procedures also allow for both the individual and the institution to take steps to correct errors, lessen damages caused by errors, or prevent future errors as appropriate.

Preventing Errors

Perhaps the single most effective strategy for reducing errors is education. Acquiring knowledge of patient safety; learning new concepts, strategies, and skills for preventing and reducing error; adjusting practice approaches; and managing the moral and ethical consequences of error all contribute to creating a culture of safety.⁶ Using information gathered by the systematic review of past errors, institutions can provide education on error-prone situations, treatment approaches or equipment.

Education on specific practice elements reduces the likelihood of misjudgment and addresses the lack of knowledge that are the two primary causes of errors identified by the Creighton University researchers.^2–4 Educational programs should provide instruction on patient safety, including basic skills and ethical and moral implications of treatment. Although our code of ethics specifies that therapists keep up-to-date, it is difficult to do so without practical knowledge. For this reason, institutions need to provide a system for advancing therapists’ education and skills. Professional-level education should include case studies, modeling, role-playing, and mentorship to address the complexity of treatment situations. Therapists have to make a commitment to developing skills, including those beyond their regular treatment areas. For example, it is important that a therapist who primarily treats patients with spinal cord injuries has a comprehensive understanding of orthopedic shoulder issues, as these are often compounding features of these patients’ presentation. Institutions can also enhance their therapists’ commitment to safety by requiring incident reports and providing grand rounds or written "error announcements" to outline situations or equipment that tend to cause errors.

Joint Commission National Patient Safety Goals and Implication for Practice

The Joint Commission accredits hospital organizations. Its accreditation procedures help organize and strengthen patient safety efforts. Joint Commission accreditation is strongly associated with implementation of patient safety systems.⁵ As part of its commitment to improving patient safety on a systems level, The Joint Commission has established National Patient Safety Goals that focus on problems in healthcare settings and how to solve them. National Patient Safety Goals are the responsibility of all staff members of the hospital, and accredited institutions are required to demonstrate efforts to meet these goals. The 2010 National Patient Safety Goals that apply to hospitals include —

• Goal 1: Improve the accuracy of patient identification: use of two patient identifiers, eliminating transfusion errors
• Goal 2: Improve the effectiveness of communication among caregivers: timely reporting of critical tests and critical results
• Goal 3: Improve the safety of using medications: labeling medications, reducing harm from anticoagulation therapy
• Goal 7: Reduce the risk of healthcare-associated infections: meeting hand hygiene guidelines, preventing multidrug-resistant organism infections, preventing central line-associated blood stream infections, preventing surgical site infections
• Goal 8: Accurately and completely reconcile medications across the continuum of care: comparing current and newly ordered medications, communicating medications to the next provider, providing a reconciled medication list to the patient settings in which medications are minimally used (not all of Goal 8 requirements are in effect)
• Goal 9: Reduce the risk of patient harm resulting from falls
• Goal 14: Prevent healthcare-associated pressure ulcers (decubitus ulcers)
• Goal 15: Identify safety risks inherent in its patient population: identifying individuals at risk for suicide⁷

While each institution is likely to develop policies and procedures, the following are examples of a therapist’s role in meeting each of the National Patient Safety Goals.

• Goal 1: The therapist should confirm the identity of the patient before beginning treatment. If the patient has an acute condition or is unfamiliar to the therapist, the therapist should conduct a brief chart review to confirm precautions and contraindications that may influence treatment.
• Goal 2: The therapist is responsible for initiating communication with other providers, especially regarding clarification orders and communicating pertinent events during patient handoff. Documentation should be clear and avoid nebulous abbreviations (see sidebar).
• Goal 3 and 8: While therapists are not directly responsible for medication administration, they are responsible for reporting any adverse reactions observed during therapy sessions. Therapists may also be involved in determining a realistic medication schedule, including medication management in ADL training, or addressing pain prior to treatment
• Goal 7: Hand washing is everybody’s business. Hands should be washed before and after patient contact. Therapists should practice this behavior regularly.
• Goal 9: Therapists are central in determining the appropriateness of patient ambulation and transfer safety. Therapists are responsible for communicating these needs to caregivers and other healthcare providers. Therapists are fall-prevention experts and should provide treatment or consultation when necessary.
• Goal 14: Therapists should be involved in establishing positioning protocols and teaching caregivers how to reduce the risk of pressure ulcers.
• Goal 15: Therapists are responsible for communicating patient status, needs, or changes to the healthcare team. It’s particularly important that therapists immediately assess and communicate suicide risk to the team. Together, they will then determine the needs and risks of the patients.

Further, to monitor significant happenings and to support systems that prevent and manage these, the Joint Commission has defined sentinel events:

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response.⁷

These sentinel events would include major medication errors, wrong site surgery, infection leading to amputation, unanticipated death of an infant, and patient suicide. In the therapy realm, the events are less likely to lead to death, but they are significant and require reporting all the same. These may include, but are not limited to, long bone fracture during floor transfers, anaphylactic allergic reaction to iontophoresis, or falls resulting in injury. Sentinel events not only include injury, but "risk thereof." This means that both sentinel events and near misses must be reported. Reporting and handling a near miss is described below.

Do Not Use” Abbreviations

In 2005, The Joint Commission established a “Do Not Use” list of abbreviations as part of its commitment to enhance patient safety and support systems to strengthen safety efforts. The list includes look-a-like abbreviations and commonly misunderstood abbreviations, which contribute to communication errors and potential sentinel events.