Abstract
Compared to other health care professions such as medicine, nursing and pharmacy, few studies have been conducted to examine the nature of practice errors in occupational and physical therapy. In an ongoing study to determine root causes, typographies and impact of occupational and physical therapy error on patients, focus group interviews have been conducted across the United States. A substantial number of harmful practice errors and/or other patient safety events (deviations or accidents) have been identified. Often these events have had moral dimensions that troubled the therapist involved. In this article, six of these transcribed cases are analyzed, using predominant bioethical theories, ethical principles and professional codes of ethics. The cases and their analyses are intended to be exemplary, improving the readers’ ability to discern and critically address similar such events. Several patient safety strategies are suggested that might have prevented the events described in these cases.
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References
Agency for Healthcare Research and Quality: 2006, Web site: http://psnet.ahrq.gov/. PS Net Patient Safety Network, Retrieved, February 14, 2006
American College of Emergency Physicians: 2003, Policy: Disclosure of Medical Errors, Approved, September 2003, http://www.acep.org/1,33205,0.html
American Medical Association: 2003, Council on Ethical and Judicial Affairs, Code of Medical Ethics. Current Opinions with Annotations. E-8.121 Ethical Responsibility to Study and Prevent Error and Harm, Adopted June 2003
American Occupational Therapy Association (AOTA): Web site: http://www.aota.org. Occupational Therapy Code of Ethics: 2005, Guidelines to the AOTA Code of Ethics, 2005/2006; American Occupational Therapy Association’s Commission on Standards and Ethics, Retrieved, February 14, 2006
American Physical Therapy Association (APTA): 2004, Web site: http://www.apta.org. Code of Ethics and Guide for Professional Conduct. Retrieved, February 14, 2006
Banja J. 2005 Medical Errors and Medical Narcissism. Sudbury MA: Jones and Barlett Publishers
Billings C.E. 1998 Some Hopes and Concerns Regarding Medical Event-reporting Systems: Lessons from the NASA Safety Reporting System. Archives of Pathology Laboratory Medicine 122(3):214–215
Bosk C.L. 1979 Forgive and Remember: Managing Medical Failures. Chicago, IL: The University of Chicago Press
Bosk C.L. 2003 Forgive and Remember: Managing Medical Failures, 2nd ed., Chicago, IL: The University of Chicago Press
Deusinger, S.S.: 1987, ‘Errors in Clinical Practice: A Critical Incident Survey of Physical Therapists in Missouri’, Washington University, Dissertation Abstracts International, 48, No. 04B
Deusinger S.S. 1992 Analyzing Errors in Practice. International Journal of Technology Assessment in Health Care 8(1):62–75
Dovey S.M., Phillips R.L. 2004 What Should We Report to Medical Error Reporting Systems? Quality and Safety in Health Care 13:322–323
Fletcher, J.J., J.M. Dorrell and M.C. Silva: December 31, 1998, ‘Whistleblowing as a Failure of Organizational Ethics’, Online Journal of Issues in Nursing. http://www.nursingworld.org/ojin/topic8/topic8_3.htm
Hundert E.M., Hafferty F., Christakis D. 1996 Characteristics of the Informal Curriculum and Trainees’ Ethical Choice. Academic Medicine 71:624–642
Institute of Medicine: 2000, To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press
Institute of Medicine: 2001, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press
Institute of Medicine: 2004, Patient Safety: Achieving a New Standard for Care. Washington, D.C.: The National Academies Press
Joint Commission on Accreditation of Healthcare Organizations: 2002, Failure Mode and Effects Analysis in Health Care: Priorities, Risk Reduction. Oakbook Terrace, IL: Joint Commission Resources, Inc
Joint Commission on Accreditation of Healthcare Organizations: 2004, The Physician’s Promise: Protecting Patients from Harm. Oakbrook Terrace, IL: Joint Commission Resources, Inc
Joint Commission on Accreditation of Healthcare Organizations: 2005, Patient Safety: Essentials for Healthcare (3rd ed.). Oakbrook Terrace, IL: Joint Commission Resources, Inc
Joint Commission on Accreditation of Healthcare Organizations: 2006, National Patient Safety Goals (Effective January 1, 2006). On-line at www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
Leape L.L. 2005 Ethical Issues in Patient Safety. Thoracic Surgery Clinics 15:493–501
Leape L.L., Berwick D.M. 2005 Five Years After ‘To Err is Human’: What have We Learned? JAMA 29:2384–2390
Lohman H., Mu K., Scheirton L. 2003 Occupational Therapists Perspectives on Practice Errors in Geriatric Settings. Physical and Occupational Therapy in Geriatrics 21(4):21–39
Marx D. 2001 Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York, NY: Columbia University
Mazor K.M., Simon S.R., Yood R.A., Martinson B.C., Gunter M.J., Reed G.W., Gurwitz J.H. 2004 ‘Health Plan Members’ Views About Disclosure of Medical Errors. Annuals of Internal Medicine 140(6):409–418
Mills P.D., Neily J., Luan D., Stalhandske E., Weeks W.B. 2005 Using Aggregate Root Cause Analysis to Reduce Falls and Related Injuries. Journal on Quality and Patient Safety 31(1):21–31
Morath J.M., Turnball J.E. 2005 To Do No Harm: Ensuring Patient Safety in Health Care Organizations. San Francisco, CA: John Wiley & Sons, Inc
Mu, K., H. Lohman and L. Scheirton: September 19, 2005, ‘To Err is Human’. OT Practice, 13–17
Mu, K., H. Lohman and L. Scheriton: 2006, ‘Occupational Therapy Practice Errors in Physical Rehabilitation and Geriatric Settings: A National Survey Study’, The American Journal of Occupational Theraphy 60, 288’297
National Patient Safety Agency: 2006, Website: http://www.npsa.nhs.uk/. Retrieved March 23, 2006
National Patient Safety Foundation: 2006, Web site: http://www.npsf.org/. Bibliography and Current Awareness Literature Alert, Retrieved February 14, 2006
Purtilo R.B. 2005 Beyond Disclosure: Seeking Forgiveness. Physical Therapy 85(11):1122–1126
Reason J. 1990, Human Error. New York, NY: Cambridge University Press
Scheirton L.S., Mu K., Lohman H. 2003 ‘Occupational Therapists’ Responses to Practice Errors in Physical Rehabilitation. American Journal of Occupational Therapy 57(3):307–314
Singh R., Naughton B., Taylor J.S., Koenigsberg M.R., Anderson D.R., McCausland L.L., Wahler R.G., Robinson A., Singh G.A. 2005 Comprehensive Collaborative Patient Safety Residency Curriculum to Address the ACGME Core Competencies. Medical Education 39(12):1195–2004
Solet D.J., Norvell M., Turan G.H., Frankel R.M. 2005 Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communications During Patient Handoffs. Academic Medicine 80(12):1094–1099
UNESCO (United Nations Educational, Scientific, and Cultural Organization): 2005, Website: http://www.unesco.org. Universal Declaration on Bioethics and Human Rights, Retrieved, February 14, 2006
Witman A.B., Park D.M., Hardin S.B. 1996 How Do Patients Want Physicians to Handle Mistakes? A Survey of Internal Medicine Patients in an Academic Setting. Archives of Internal Medicine 156:2565–2569
World Conferation for Physical Therapists: 1995, Website: http://www.wcpt.org/. Declaration of Principle: Ethical Principles. Retrieved, February 14, 2006
World Federation of Occupational Therapists: 2004, Website: http://www.wfot.org.au/. Code of Ethics. Retrieved, February 14, 2006
Wu A.W., Cavanaugh T.A., McPhee S.J., Lo B., Micco G.P.J. 1997 To Tell the Truth: Ethical and Practical Issues in Disclosing Medical Mistakes to Patients. General Internal Medicine 12:770–775
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Scheirton, L.S., Mu, K., Lohman, H. et al. Error and patient safety: Ethical analysis of cases in occupational and physical therapy practice. Med Health Care and Philos 10, 301–311 (2007). https://doi.org/10.1007/s11019-007-9049-3
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DOI: https://doi.org/10.1007/s11019-007-9049-3