An Analysis of Adverse Events in the Rehabilitation Department: Using the Veterans Affairs Root Cause Analysis System

Hagley, Gregory; Mills, Peter D.; Shiner, Brian; Hemphill, Robin R.

doi:10.1093/ptj/pzy003

Cited by 17 publications

(22 citation statements)

References 28 publications

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“…In 1845 sessions held, 128 AEs were reported, confirming previous findings that, despite the lack of reporting, AEs do occur in the field of physiotherapy 24 …”

Section: Discussionsupporting

confidence: 82%

Adverse Events of Physiotherapy Interventions in Parkinsonian Patients

Caniça¹,

Bouça‐Machado

Rosa

et al. 2022

Movement Disord Clin Pract

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Background Physiotherapists have an ethical, professional, and regulatory responsibility for safety in all aspects of patient care. Notwithstanding, the adverse events issue has been inadequately addressed in the rehabilitation research field. Objectives To determine the frequency and characterize the adverse events that occur during or in between physiotherapy sessions for parkinsonian syndromes. Methods An exploratory clinical study was conducted. Physiotherapists were asked to actively report the adverse events that occurred during or between sessions for parkinsonian syndromes. Results A total of 100 patients were enrolled in the study, which resulted in 1845 sessions. The most common adverse events reported were falls, pain/discomfort, and hypotension, with a total of 128 adverse events reported. Conclusions During the physiotherapy sessions, adverse events do occur. Future research should clarify the relationship between AE occurrence and the type of intervention as well as causality and risk‐minimization strategies.

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“…In 1845 sessions held, 128 AEs were reported, confirming previous findings that, despite the lack of reporting, AEs do occur in the field of physiotherapy 24 …”

Section: Discussionsupporting

confidence: 82%

Adverse Events of Physiotherapy Interventions in Parkinsonian Patients

Caniça¹,

Bouça‐Machado

Rosa

et al. 2022

Movement Disord Clin Pract

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“…In our study, the proportion of strong measures was 2% and even lower than in previous studies. The average number of measures per report was also lower than in the literature (1.5 measures versus 3 to 5 measures per incident report) 3,5,11,12 …”

Section: Discussionmentioning

confidence: 65%

Strength of Safety Measures Introduced by Medical Practices to Prevent a Recurrence of Patient Safety Incidents: An Observational Study

et al. 2021

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The aim of this study was to analyze the strength of safety measures described in incident reports in outpatient care.Methods: An incident reporting project in German outpatient care included 184 medical practices with differing fields of specialization. The practices were invited to submit anonymous incident reports to the project team 3 times for 17 months. Using a 14-item coding scheme based on international recommendations, we deductively coded the incident reports and safety measures. Safety measures were classified as "strong" (likely to be effective and sustainable), "intermediate" (possibly effective and sustainable), or "weak" (less likely to be effective and sustainable). Results:The practices submitted 245 incident reports. In 160 of them, 243 preventive measures were described, or an average of 1.5 per report. The number of documented measures varied from 1 in 67% to 4 in 5% of them. Four preventive measures (2%) were classified as strong, 37 (15%) as intermediate, and 202 (83%) as weak. The most frequently mentioned measures were "new procedure/policy" (n = 121) and "information/notification/warning" (n = 45). Conclusions:The study provides examples of critical incidents in medical practices and for the first time examines the strength of ensuing measures introduced in outpatient care. Overall, the proportion of weak measures is (too) high, indicating that practices need more support in identifying strong measures.

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“…The care provided by rehabilitation professionals is generally safe, but adverse events do occur. 8 Some of the commonest adverse events; fall related event, pain and soreness associated with muscle injury, infection due to medical care ,wound infection, decubitus ulcer, hospital acquired pneumonia etc. were more commonly seen in the clinical practices.…”

Section: Rehabilitative Care and Errorsmentioning

confidence: 99%

Patient safety issues in rehabilitation for person with locomotor disabilities: a review

Deka

Gogoi

2019

Int J Res Med Sci

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Since the publication of the Institute of medicine report, To Err Is Human: Building a safer health system, notes that errors in health care are a significant cause of death and injury and the emphasis on patient safety has steadily increased. The rehabilitation professionals engaged for the management of patient with locomotor disabilities should incorporate elements of patient safety into their practices and also to stimulate research associated with prevalence of analysis of error/harm which occurs during the rehabilitation phase and also to develop and validate certain specific measuring tools and instruments for patient safety issues.

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An Analysis of Adverse Events in the Rehabilitation Department: Using the Veterans Affairs Root Cause Analysis System

Cited by 17 publications

References 28 publications

Adverse Events of Physiotherapy Interventions in Parkinsonian Patients

Adverse Events of Physiotherapy Interventions in Parkinsonian Patients

Strength of Safety Measures Introduced by Medical Practices to Prevent a Recurrence of Patient Safety Incidents: An Observational Study

Patient safety issues in rehabilitation for person with locomotor disabilities: a review

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