PMID- 29325162
OWN - NLM
STAT- MEDLINE
DCOM- 20190523
LR  - 20190523
IS  - 1538-6724 (Electronic)
IS  - 0031-9023 (Linking)
VI  - 98
IP  - 4
DP  - 2018 Apr 1
TI  - An Analysis of Adverse Events in the Rehabilitation Department: Using the 
      Veterans Affairs Root Cause Analysis System.
PG  - 223-230
LID - 10.1093/ptj/pzy003 [doi]
AB  - BACKGROUND: Root cause analyses (RCA) are often completed in health care settings 
      to determine causes of adverse events (AEs). RCAs result in action plans designed 
      to mitigate future patient harm. National reviews of RCA reports have assessed 
      the safety of numerous health care settings and suggested opportunities for 
      improvement. However, few studies have assessed the safety of receiving care from 
      physical therapists, occupational therapists, or speech and language pathology 
      pathologists. OBJECTIVE: The objective of this study was to determine the types 
      of AEs, root causes, and action plans for risk mitigation that exist within the 
      disciplines of rehabilitation medicine. DESIGN: This study is a retrospective, 
      cross-sectional review. METHODS: A national search of the Veterans Health 
      Administration RCA database was conducted to identify reports describing AEs 
      associated with physical therapy, occupational therapy, or speech and language 
      pathology services between 2009 and May 2016. Twenty-five reports met the 
      inclusion requirements. The reports were classified by the event type, root 
      cause, action plans, and strength of action plans. RESULTS: Delays in care 
      (32.0%) and falls (28.0%) were the most common type of AE. Three AEs resulted in 
      death. RCA teams identified deficits regarding policy and procedures as the most 
      common root cause. Eighty-eight percent of RCA reports included strong or 
      intermediate action plans to mitigate risk. Strong action plans included 
      standardizing emergency terminology and implementing a dedicated line to call for 
      an emergency response. LIMITATIONS: These data are self-reported and only AEs 
      that are scored as a safety assessment code 3 in the system receive a full RCA, 
      so there are likely AEs that were not captured in this study. In addition, the 
      RCA reports are deidentified and so do not include all patient characteristics. 
      As the Veterans Health Administration system services mostly men, the data might 
      not generalize to non-Veterans Health Administration systems with a different 
      patient mix. CONCLUSIONS: Care provided by rehabilitation professionals is 
      generally safe, but AEs do occur. Based on this RCA review, the safety of 
      rehabilitation services can be improved by implementing strong practices to 
      mitigate risk to patients. Checklists should be considered to aid timely decision 
      making when initiating an emergency response.
FAU - Hagley, Gregory W
AU  - Hagley GW
AD  - White River Junction VA Medical Center, White River Junction, Vermont, and 
      Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
FAU - Mills, Peter D
AU  - Mills PD
AD  - National Center for Patient Safety, White River Junction Field Office, White 
      River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New 
      Hampshire.
FAU - Shiner, Brian
AU  - Shiner B
AD  - White River Junction VA Medical Center and Geisel School of Medicine at 
      Dartmouth.
FAU - Hemphill, Robin R
AU  - Hemphill RR
AD  - Quality and Safety, VCU Health, and School of Medicine, Virginia Commonwealth 
      University, Richmond, Virginia.
LA  - eng
PT  - Journal Article
PT  - Research Support, U.S. Gov't, Non-P.H.S.
PL  - United States
TA  - Phys Ther
JT  - Physical therapy
JID - 0022623
SB  - IM
MH  - Accidental Falls/statistics & numerical data
MH  - Adult
MH  - Aged
MH  - Cross-Sectional Studies
MH  - Female
MH  - Hospital Mortality
MH  - Hospitals, Veterans/*organization & administration
MH  - Humans
MH  - Male
MH  - Medical Errors/statistics & numerical data
MH  - Middle Aged
MH  - Organizational Policy
MH  - Patient Care/*standards
MH  - Quality of Health Care
MH  - Rehabilitation Centers/*organization & administration
MH  - Retrospective Studies
MH  - Risk Factors
MH  - *Root Cause Analysis
MH  - Safety Management
MH  - Time-to-Treatment
MH  - United States
MH  - United States Department of Veterans Affairs
EDAT- 2018/01/13 06:00
MHDA- 2019/05/24 06:00
CRDT- 2018/01/12 06:00
PHST- 2017/03/24 00:00 [received]
PHST- 2018/01/08 00:00 [accepted]
PHST- 2018/01/13 06:00 [pubmed]
PHST- 2019/05/24 06:00 [medline]
PHST- 2018/01/12 06:00 [entrez]
AID - 4794957 [pii]
AID - 10.1093/ptj/pzy003 [doi]
PST - ppublish
SO  - Phys Ther. 2018 Apr 1;98(4):223-230. doi: 10.1093/ptj/pzy003.