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at the time of the study. OBJECTIVE. This qualitative focus group study investigated the strategies to prevent or reduce practice errors used by occupational therapists who practice in physical rehabilitation and geriatrics. METHOD. A total of 34 occupational therapists from four geographic regions across the United States participated in four focus groups. Participants worked in the areas of physical rehabilitation or geriatrics and had a minimum of 1 year of practice. Participants responded to open-ended, guiding questions. Data collected from the focus groups were analyzed qualitatively for themes. RESULTS. Analysis of the collected data yielded four themes related to specific strategies occupational therapists use to prevent or reduce practice errors: (1) strengthen orientation and mentoring for new therapists, (2) ensure competency through performance competency checks, (3) enhance existing or establish new safety policies and procedures, and (4) advocate for the profession and for systemic change. CONCLUSION. Findings of the study suggest that occupational therapists implement various discrete strategies to prevent or reduce practice errors and improve client safety. Occupational therapy practice and professional training must emphasize the inevitability of practice errors; the importance of orientation and training, including assertiveness training; and the inclusion of performance-based competency checks.

Compared to other health care professions such as medicine, nursing and pharmacy, few studies have been conducted to examine the nature of practice errors in occupational and physical therapy. In an ongoing study to determine root causes, typographies and impact of occupational and physical therapy error on patients, focus group interviews have been conducted across the United States. A substantial number of harmful practice errors and/or other patient safety events (deviations or accidents) have been identified. Often these events have had moral dimensions that troubled the therapist involved. In this article, six of these transcribed cases are analyzed, using predominant bioethical theories, ethical principles and professional codes of ethics. The cases and their analyses are intended to be exemplary, improving the readers' ability to discern and critically address similar such events. Several patient safety strategies are suggested that might have prevented the events described in these cases.