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Eggmann S1, Stoller N2, Verra ML1
1Bern University Hospital, Department of Physiotherapy, Inselspital, Bern, Switzerland, 2Bern University Hospital, Department of Quality and Safety Management, Inselspital, Bern, Switzerland
Background: Modern health-care is a highly complex system prone to unwanted errors. The concept of patient safety aims to reduce the risk of unnecessary harm from health-care interventions by engaging patients, using checklists or through effective communication. However, identification and analysis of contributing factors are essential to learn from errors and to prevent future incidents. For this purpose, many hospitals employ a critical incident reporting system (CIRS), yet physiotherapists are often exempt or ignorant. While errors from physiotherapists are rarely life-threatening, they might result in serious patient harm. To date, physiotherapy errors are poorly studied and often kept silent.
Purpose: This practice development project aimed to raise physiotherapists' awareness of patient safety issues, to create a safety culture and to introduce a pilot CIRS in a physiotherapy unit of a university teaching hospital in order to stimulate learning from others.
Methods: This pilot project was conducted in the respiratory subdivision of the Department of Physiotherapy at the Inselspital, Bern University Hospital in Switzerland. The respiratory unit employs 20 physiotherapists who were educated about the fundamentals of patient safety. Special emphasis was given to the concept of human fallibility and system improvement. The pilot was conducted from February until July 2018 with the goal to identify common errors and to promote learning. The CIRS adhered to common fundamentals like voluntariness, anonymity, confidentiality, independency and freedom from sanction. The pilot CIRS was managed with Excel ensuring a clear structure with standard notification procedures (event description, measures taken, improvement suggestions) that facilitated easy access and immediate reporting. Due to the lack of research in the area of physiotherapy errors, physiotherapists were encouraged to submit any incident relevant to patients' safety. All reports were subsequently analysed for root causes by the authors.
Results: Twenty-nine incidents were reported during the 6-month pilot CIRS. All reports were analysed and accessible feedback was provided within the CIRS system as well as with two team meetings for further discussion. These meetings were well received and physiotherapists seemed eager to discuss and learn from the reported incidents. These included mostly structural factors (52%) or unsafe medical care with near-misses (28%), delayed or missed treatments (14%) and others (7%). Structural factors arose largely due to poor training, miscommunications or environmental pressures. Subsequently, interface problems were discussed with the involved clinics and route directions for physiotherapy outpatients were improved.
Conclusion(s): The introduction of a pilot CIRS increased awareness of risks, improved reporting and supported the development of a safety culture in a physiotherapy unit of a university hospital during the evaluation period. Consequently, the current hospital-wide CIRS will be extended to include the whole Department of Physiotherapy following education and the formation of a taskforce responsible with incident handling.
Implications: Physiotherapists are open to talk about errors and eager to enhance the quality of their work. A physiotherapy-based CIRS might lower reporting barriers because errors primarily remain within their profession where mutual trust and a shared vision of patient safety is established. Nevertheless, more research is needed to understand error causes and prevent future harm.
Keywords: patient safety, critical incident reporting system, error prevention
Funding acknowledgements: No funding has been received.
Purpose: This practice development project aimed to raise physiotherapists' awareness of patient safety issues, to create a safety culture and to introduce a pilot CIRS in a physiotherapy unit of a university teaching hospital in order to stimulate learning from others.
Methods: This pilot project was conducted in the respiratory subdivision of the Department of Physiotherapy at the Inselspital, Bern University Hospital in Switzerland. The respiratory unit employs 20 physiotherapists who were educated about the fundamentals of patient safety. Special emphasis was given to the concept of human fallibility and system improvement. The pilot was conducted from February until July 2018 with the goal to identify common errors and to promote learning. The CIRS adhered to common fundamentals like voluntariness, anonymity, confidentiality, independency and freedom from sanction. The pilot CIRS was managed with Excel ensuring a clear structure with standard notification procedures (event description, measures taken, improvement suggestions) that facilitated easy access and immediate reporting. Due to the lack of research in the area of physiotherapy errors, physiotherapists were encouraged to submit any incident relevant to patients' safety. All reports were subsequently analysed for root causes by the authors.
Results: Twenty-nine incidents were reported during the 6-month pilot CIRS. All reports were analysed and accessible feedback was provided within the CIRS system as well as with two team meetings for further discussion. These meetings were well received and physiotherapists seemed eager to discuss and learn from the reported incidents. These included mostly structural factors (52%) or unsafe medical care with near-misses (28%), delayed or missed treatments (14%) and others (7%). Structural factors arose largely due to poor training, miscommunications or environmental pressures. Subsequently, interface problems were discussed with the involved clinics and route directions for physiotherapy outpatients were improved.
Conclusion(s): The introduction of a pilot CIRS increased awareness of risks, improved reporting and supported the development of a safety culture in a physiotherapy unit of a university hospital during the evaluation period. Consequently, the current hospital-wide CIRS will be extended to include the whole Department of Physiotherapy following education and the formation of a taskforce responsible with incident handling.
Implications: Physiotherapists are open to talk about errors and eager to enhance the quality of their work. A physiotherapy-based CIRS might lower reporting barriers because errors primarily remain within their profession where mutual trust and a shared vision of patient safety is established. Nevertheless, more research is needed to understand error causes and prevent future harm.
Keywords: patient safety, critical incident reporting system, error prevention
Funding acknowledgements: No funding has been received.
Topic: Professional issues; Professionalism & ethics; Service delivery/emerging roles
Ethics approval required: No
Institution: Department of Physiotherapy, Inselspital, Bern University Hospital
Ethics committee: Internal Board
Reason not required: This was a practice development project and did not involve human participants.
All authors, affiliations and abstracts have been published as submitted.
