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  • PTJ: To Avoid Adverse Events, Rehab Facilities Need to Get to the Root of the Problem

    While rehabilitation services are “generally safe,” say Veterans Health Administration (VHA) researchers, “low risk does not mean no risk”—and adverse events still occur. A new study published in PTJ, APTA's scientific journal, outlines several concrete suggestions for improving patient safety that may apply to many civilian rehabilitation facilities.

    When serious adverse events are reported in the VHA, the facility often performs a root cause analysis to identify flawed systems, processes, or environmental conditions that need to be addressed. Authors examined 25 adverse event reports associated with physical therapy, occupational therapy, and speech-language pathology that occurred between 2009 and 2016.

    Researchers found that the most frequent adverse events were delays in care (32%) and falls (28%). Adverse events were most often caused by staff errors in policy and procedures (38.3%) and communications (25.5%).

    Authors also categorized the prescribed action plans as “strong,” “intermediate,” or “weak.” They concluded that 88% of action plans were strong, such as standardizing emergency terminology, or intermediate, such as improving documentation and verbal communication. The majority of recommendations, authors write, included changes in policy and procedures (48.8%) and staff training and education (21.3%).

    Authors' recommendations for mitigating risk of adverse events include:

    • Establishing clear emergency procedures and practicing them “at regular intervals with all staff”
    • Implementing strong actions to avoid adverse events, such as posting signs and standardizing terms for an emergency scenario
    • Ensuring that clinical staff have the skills to recognize “red flag” situations before they become emergencies
    • Using checklists to quickly identify patients at high risk of “deteriorating health” and those with acute illness who need immediate referral to another provider

    “Guidelines are beneficial, but unique clinics will need customized strong actions to optimize patient safety,” authors note. “Rehab departments can strengthen their safety record by developing practices and strong actions to ensure that all staff are prepared for an emergency response.”

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.