Good Practice: Adverse Events

  •   April 1, 2015


By: Leanne Loranger, PT

“The price of greatness is responsibility.” - Churchill

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 adverse events. By the time you finish reading this article I hope that I will have convinced you of the following:

  1. Adverse events matter to patients and they matter to the profession.
  2. One adverse event is one too many.
  3. Adverse events happen in ALL areas of physiotherapy practice. This is not someone else’s issue.
  4. Having a way to track and review adverse events 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 adverse events in your practice environment.
 

Background


The World Health Organization recently came out with universal terminology to discuss adverse events, and although Adverse Event is the term that many, myself included, are most familiar with 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 language matter? Well for one thing, it ensures that there is a universal 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, leading physiotherapists to believe that adverse events happen to nurses and doctors, not us. In private practice there’s talk of adverse events 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, but not to physiotherapists.

The reality is that one high profile incident could radically change the faith that the public has in our 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 adverse event 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.


Physiotherapy Alberta is committed to supporting excellence in practice and ensuring patient safety. In pursuing these goals we have worked with the Health Quality Council of Alberta to review adverse events related to needling practices, participated in research in spinal manipulation safety, contributed to the fall prevention initiative Finding Balance, and are actively engaged in our new quality initiative.

 

Check out our video on patient safety incidents.

 

References:

  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.
  5. Health Quality Council of Alberta. Review of Adverse Events related to Dry Needling Practices by Physiotherapists in Alberta. November 1, 2013.
  6. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. British Medical Journal 2000; 320: 759-763.
  7. Institute for Healthcare Improvement. Ask ‘why’ five times to get to the root cause. Available at: http://www.ihi.org/resources/Pages/ImprovementStories/AskWhyFiveTimestoGettotheRootCause.aspx Accessed on August 29, 2014.