Preventing Practice Errors and Improving Patient Safety: An Examination of Case Studies Reflecting Common Errors in Occupational Therapy Practice

Article excerpt

Like other health care professionals, occupational therapists make errors in clinical practice. Only recently have we systematically studied errors in occupational therapy practice. In this report, key findings from two grant projects in occupational therapy practice errors are further examined. Specifically, this report includes an in-depth analysis of five examples of occupational therapy practice errors in physical rehabilitation and geriatric settings. These examples from the five most commonly reported causes of errors found in a national sutvey study on occupational therapy errors are misjudgment, lack of preparation, lack of experience, lack of knowledge, and insufficient communication. For each of the five examples, hypothesized causes of errors and their implications for professional education training and current occupational therapy practice are explored. It is hoped that this report helps to better inform practice and educational approaches to contribute to the prevention and reduction of occupational therapy and other health care practice errors. J Allied Health 2008; 37:242-247.

MEDICAL ERRORS occur commonly in health care practice and can sometimes lead to minor or major patient conse- quences. The Institute of Medicine defines medical error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."1 Another definition of error is an "unwarranted failure of action or judgment to accommodate the standard of care."2 In addition, an error may be defined as "an unintended act (by omission or commission) or one that does not achieve its intended outcome."3 While definitions of error vary, a consequence of errors occurring may be client harm or even death. Hospital errors are the eighth leading cause of death in the United States, surpassing deaths from motor vehicle accidents or breast cancer.1 In recent years, researchers have studied errors in several medical fields, including medicine,4,5 pharmacy,6,7 and nursing.8-10 Examination of practice errors in occupational therapy, however, is limited. We define occupational therapy errors as "omissions or commissions in practice for which occupational therapists felt responsible; which had serious and/or potentially serious physical and/or psychological consequences for the patient, and which would be judged wrong by knowledgeable peers at the time they occurred."11

Since 2000, a research team from Creighton University School of Pharmacy and Health Professions has conducted two grant projects to examine occupational therapy practice errors in physical rehabilitation and geriatrics, two of the major practice settings for occupational therapists.11-14 These multistage research projects used mixed methods consisting of qualitative focus groups (12 focus groups wirii 69 occupational therapists) and quantitative survey research (245 occupational therapists nationwide participated in the survey). Findings of qualitative focus groups revealed occupational therapists' understanding of the concept of errors, root causes, impact, and prevention of errors. Within both qualitative (n = 69) and quantitative research studies (n = 245), occupational therapists reported more rhan 300 practice errors from their own practice and the practice of colleagues.11-14

As one facet of the national survey study, the researchers investigated the causes of errors by occupational therapists practicing in physical rehabilitation and geriatric settings. Results of the survey study revealed that the most frequently reported causes of errors were misjudgment, inadequate preparation, lack of experience, inadequate knowledge, and miscommunication between professionals.13

The purpose of this report is to present examples of the five most commonly reported causes of occupational therapy errors in physical rehabilitation and geriatrics practice. From each of the five categories, the research team chose by consensus to discuss a case study example that represented that category. …