The first conference on patient safety and systems error took place at the Annenberg Center for Health Sciences in 1996. Many of the contributors at this conference pushed the idea that there must be a global sharing of the information about medical errors so that more could be learned to implement better lessons for patient safety. Everyone from executives to governing boards, clinicians and managers of healthcare delivery were encouraged and coached to think in terms of correcting the systems and processes that facilitate medical errors. Teamwork training became the cornerstone for constructing the field of patient safety. It is imperative that clinicians respect and work with other clinicians and support personnel as a team to correct the process/system.
In 2001 the Federal Patient Safety Task Force was established within the Department of Health and Human Services. The task force was charged with developing data to help avert risks to patients. The Joint Commission became involved to help push for information to develop solutions to process errors and to not place blame on individuals. The mission of the Joint Commission is “to continuously improve the safety and quality of care provided to the public”. To accomplish this mission requires healthcare organizations to:
1) Have a process in place to recognize sentinel events (avoidable errors).
2) Conduct thorough and credible root cause analysis that focus on process and system factors, not on individual blame.
3) Document a risk reduction strategy and internal corrective action plan within 45 days of the organization becoming aware of the sentinel event.
It is important to remember that the Joint Commission encourages, but does not require reporting of sentinel events.
In 2001, the Joint Commission stated 4 goals:
1) To have a positive impact on improving patient care, treatment, and services and preventing sentinel events.
2) To focus the attention of an organization that has experienced a sentinel event on understanding the factors that contributed to the event (such as underlying causes, latent conditions and active failures in defense systems or organizational culture), and on changing the organization’s culture, systems, and processes to reduce the probability of such an event in the future.
3) To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention.
4) To maintain the confidence of the public and accredited organizations in the accreditation process.
The 2014 National Patient Safety Goals provide by the Joint Commission can be found at http://www.jointcommission.org/standards_information/npsgs.aspx
As patient safety is a new and evolving field, there is still not a well-defined definition of patient safety by the organizations that have propelled its existence. The Institute of Medicine defined patient safety as “freedom from accidental injury”. Emanuel, et.al defined patient safety as: a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of and maximizes recovery from adverse events.
The goal of patient safety is to minimize adverse events and eliminate preventable harm in health care. The objective of the safety sciences is to design systems that approach “fail-safe” conditions (the system does not let the operator perform an improper function). For example, in the operating room, the coupling for oxygen has been redesigned so that no other gas can attach to that particular coupling. If the operator wants to give oxygen to the patient, he cannot attach anything else, in other words, the ability to fail has been removed.
Vincent identified seven elements that influence safety:
1) Organization and management factors
2) Work environment factors
3) Team factors
4) Task factors
5) Individual factors
6) Patient characteristic
7) External environment factors
Patient safety applies to therapeutic intervention (process/systems). The more complex the process, the greater risk for chaos and error. So how do we achieve patient safety? We must have high-reliability design. High-reliability designs are resilient even when unpredictable events occur. As we all know, in health care, unpredictable events are more commonplace than not.
Patient centered care has become the vision for patient safety and is focused on interdisciplinary teams and families. Every member of the healthcare team, family members and patients must work in unison to help insure safety. Many healthcare organizations have developed interesting ways to help everyone keep safety in mind and to help as a community to reduce medical errors. For example, at the Kirkland Clinic located on the UAB Health System Campus in Birmingham, Alabama, the elevator doors for the clinic are adorned with eye- catching photographs and “Safety Tips” that patients, family members and clinic staff see while awaiting one of the 6 elevators.
For true patient safety to occur, all medical professionals must have a patient safety vigilance. Every clinician must have the sixth sense to know when something is not right which enable many adverse events to be avoided.
Medication and Physical Therapy Management
Regardless of the setting in which a physical therapist works, inpatient, outpatient, nursing homes, pediatrics, sports, or home health, therapists will come into contact and treat patients that are on medications every day. You may ask why this is so important, and the resounding answer is simply this, 56% of preventable adverse events occur from the ordering of medication and another 34% occur from the administration of medications. If a mistake occurs during ordering or administration, the physical therapist might very well be able to pick up on an error as they perform 3 basics each time they provide treatment for a patient:
1) Review the patient’s medications at every visit.
2) Review the effect of the medications/side effects/contraindications.
3) Review how the current medications will respond during the therapy session.
By administering these three basics and communicating with nurses or the prescribing physician when a discrepancy is identified, the physical therapist can and will help to avoid preventable adverse events involving medications.
Along with other clinicians, the physical therapist should also help to educate patients to increase patient safety. Therapists should always encourage patients to ask the following 5 questions which were created by the National Client Safety Partnership in 1999:
1) Is this the drug my doctor (or other healthcare provider) ordered? What is the trade and generic name of the medicine?
2) What is the drug for? What is it supposed to do?
3) How and when am I supposed to take it and for how long?
4) What are the likely side effects? What should I do if they occur?
5) Is this medication safe to take with other over-the-counter or prescription medications, or dietary supplements, that I am already taking? What food, drink, activities, dietary supplements or other medication should be avoided while taking this medication?
Some of the high risk/high alert medications that physical therapists should be familiar with include: potassium chloride, intravenous insulin and anticoagulants (heparin and warfarin). There is very significant injury potential when taking heparin and warfarin for patients with atrial fibrillation or DVT and bleeding complications. It is important to remember that therapy patients who are at risk for DVT and venous thromboembolism include: general surgery; orthopedic; neurosurgery; total hip; total knee and hip fracture repairs.
Medications can and do play a part in how a patient responds during physical therapy. Therapists must make it a point to always be aware of any and all medications and their effects during therapy. The physical therapist should be aware of the interactions of medications if the patient is taking multiple medications. It is important to note that during the first few minutes of every therapy session that the therapist remember to review the 3 basics and ensure that he/she is aware of any change or if the patient has added medications from another physician.
Absorption of the medication will vary with the medication and the individual, so monitoring the patient’s response to therapy is vital. The disposition of the medications within the patient’s system can be altered by exercise, the use of modalities or manual therapy. As a reminder, let’s review some of the responses:
Exercise – intense exercise will alter blood flow, so the ability of the medication to move to the needed area can be incorrect or cause an adverse reaction.
Modalities – cooling will decrease the delivery of medication to the needed site and conversely, heat will increase delivery of medication.
Manual therapy – soft tissue mobilization close to an injection site could potentially increase medication absorption rate.
Physical therapy education is now changing to include training in pharmacology and much of this is based on the program the US Army began over 20 years ago that allowed physical therapists to prescribe certain medications. Physical therapists can presently discuss medications, but cannot interpret the use of the medications as it is beyond the scope of practice.
Below we have provided some of the common medications for different groups to keep in mind during treatment:
Outpatient and Sports Medicine
Anti-inflammatories, Narcotics, Steroids, Herbal Medications, Alcohol, Recreational Drugs, and Antidepressants
Anti-spasticity, Seizure Medications, Cardiac Medications, Pain Medications, and Chemotherapy
Geriatrics and Home Health
Cardiac Medications, Antidepressants, Narcotics, OTCs, Alcohol, Recreational Drugs, Anticoagulants, Laxatives, Stool Softeners, Anticholinesterase Drugs, Cough Medicines, Expectorants, Antihistamines, Allergy Medications, and Motion Sickness Drugs