Patient safety in medical settings has become a major concern. As more and more individuals seek rehabilitative care for their medical conditions or are referred to rehabilitation specialists with increasingly complex medical conditions, the issue of patient safety in the rehabilitation setting takes on added importance. This article introduces the concepts of patient safety, cognitive biases, systems thinking, and quality improvement as they apply to the rehabilitation medicine.
It has been estimated that 98,000 people die each year because of medical errors. Thirty-six percent of patients admitted to hospitals sustain an injury secondary to a medical error. In 9% of those admitted, the error was life threatening and in 2%, the error was thought to have contributed to the patient’s death. Two percent to 14% of patients admitted to hospitals have a medication-related error, and 35% to 40% of medical diagnoses are wrong according to autopsy reports, particularly in cerebrovascular disease and infections. Approximately 1 in 10 admissions to a hospital will result in an adverse event, with about half of these being preventable. It has been estimated that the average patient in an intensive care unit has 1.7 errors in his or her care per day and the average hospitalized medical patient experiences one medication error per day. In addition to causing patient harm, preventable adverse events have a significant financial impact on health care. The Institute of Medicine report has estimated that the overall cost in the United States for preventable adverse events was between $17 billion and $29 billion.
Medical errors occur in other health care settings besides hospitals. In 2003, a published study reported that 25% of patients in ambulatory care practices had experienced adverse drug events. Thirteen percent of these events were deemed serious. The medication classes that were most involved were the selective serotonin reuptake inhibitors (10%). Nonsteroidal antiinflammatory agents were involved in 8% of adverse drug events. With the continuing trend of medicine pushing care toward outpatient settings, especially in rehabilitation medicine, the discussion and importance of patient safety must be stressed in all aspects of patient care.
This past year, we experienced the first member of the baby boom generation reach the age of 65 years. As more of that generation continues to age, more Americans will be undergoing rehabilitation in a variety of settings each year. These settings include (1) acute medical wards, (2) surgical wards, (3) intensive care units, (4) inpatient rehabilitation units, (5) subacute rehabilitation units in nursing homes, (6) outpatient facilities, and (7) home settings. As they are moving through this continuum of care, they are at risk of sustaining injuries that are related to their medical or rehabilitative treatments.
There are 2 goals for this article: (1) provide rehabilitation clinicians with an overview of patient safety as it applies to rehabilitation medicine and (2) provide an overview and framework for the improvement of quality in the delivery of rehabilitative care.
Patient safety has been defined as “freedom from accidental injury.” A distinction has to be made between patient adverse outcomes that are caused by patients’ medical conditions from an adverse event, which is harm to patients as a result of medical intervention. Another distinction that needs to be made is the separation of nonpreventable adverse events from preventable adverse events. Nonpreventable adverse events are events when patients experience harm from their medical care in the absence of any errors (ie, from acceptable complications of surgery or medication side effects).
The safety literature commonly defines an error as an “act of commission” (doing something wrong) or “omission” (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome. For instance, ordering a medication for a patient with a documented allergy to that medication would be an act of commission. Failure to prescribe a proven medication with major benefits for an eligible patient (eg, low dose unfractionated heparin as venous thromboembolism prophylaxis for a patient after hip replacement surgery) would be an act of omission. There are 2 types of medical errors: slips and mistakes. Slips are unconscious errors caused by an interruption in a routine while the person is not fully focused on the task. There are several reasons for the lack of focus and some examples include fatigue, lack of sleep, alcoholism, anxiety, and anger. Mistakes are errors caused by lack of knowledge; however, mistakes can be influenced by the same factors as mentioned for slips as well as unrealistic workloads and schedules and a lack of adequate training. Although most preventable adverse events involve errors, not all of them do, and many safety experts prefer to highlight preventable adverse events rather than errors as their main target of the safety field.
Patient safety and cognitive biases in the practice of rehabilitation medicine
Making good clinical decisions with patients’ best interests in mind is a cornerstone of patient safety in rehabilitation medicine. Cognitive errors in decision making on the part of clinicians can lead to medical errors that can have an adverse impact on patient care. This point is especially important because there is significant variability among physicians regarding diagnosis and treatment. This next section addresses some of the cognitive biases that clinicians have in diagnosing and treating patients and general strategies to minimize them. There are several types of cognitive errors in decision making. In the next section, some types of cognitive errors are described and some rehabilitation medicine examples are provided. They are the following:
Convergence: A key diagnostic dilemma that clinicians face with patient safety implications is the quick convergence on a singular diagnosis or treatment (and excluding other possible alternatives) and then anchoring their course of action to that diagnosis or treatment, even when the outcome may not be positive. An example is assuming that the fall of an elderly patient is caused by a simple slip on a loose rug but not considering the possibility of loss of balance caused by a side effect of a medication that was recently started or orthostatic changes secondary to dehydration.
Over-reliance: This bias is the over-reliance and application of a limited range of diagnostic options and treatments to a broad variety of conditions when the diagnosis and treatment options are uncertain or the clinician has limited knowledge about the condition: For example, limited experience in the care of spinal cord injuries may lead a clinician to think that swelling in a paralyzed limb is a deep vein thrombosis, excluding the possibility that a recent fall may have caused a fracture in the insensate limb.
Pattern recognition and comparison with the current situation: In his book, How Doctors Think , Jerome Groopman writes about how doctors are trained to think. He describes the use of prototypes in which the decision making is based on a knowledge of certain prototypes for a condition and then matching patients’ symptoms and signs against that prototype. However, this way of thinking leads to the exclusion of less-common conditions (ie, zebras) when they do not fit the prototype or when patients have an atypical presentation of the condition. He describes “zebra retreat” in which doctors are not as likely to make a diagnosis of a rare condition because there is a considerable amount of effort and cost in identifying these conditions or they may not have much first-hand experience with them. For example, an inexperienced physician may attribute the swelling in the arm of a patient with a history of breast cancer to lymphedema and exclude the possibility of deep vein thrombosis or metastatic disease as contributing factors. Another example is an atypical presentation of vascular claudication in a limb in a patient that also has a history of neurogenic claudication in that limb.
Confirmation bias: In this type of bias, data are picked that support a certain diagnosis or treatment course and data that contradict that diagnosis or treatment are discounted or excluded. Therefore, the clinician sees things that he or she wants to see. For example, a physician who commonly treats low back pain may attribute the cause of a patient’s pain to a myofascial origin and not consider an alternative explanation, such as referred pain from metastatic disease to the spine.
Cause-and-effect bias: In this bias, a faulty assumption of cause and effect or a singular explanation (as opposed to multiple linked explanations) for a clinical condition is chosen because it supports a favored diagnosis and treatment. This bias can be linked with other types of biases, such as the confirmation bias in which more weight is assigned to data that confirm the clinician’s favored diagnosis. An example is attributing a patient’s inability to take pain medications as prescribed to noncompliance with the treatment plan but not taking into account the complexity of the titration schedule coupled with the patient’s cognitive impairment and limited social support as contributing causes.
Overconfidence: This bias is the belief that a clinician’s diagnosis and treatment is the right one for a patient because similar presentations in the past by other patients were also given the same diagnosis or treatment with positive outcomes. However, the fallacy here is that not all situations are exactly the same when contrasted to previous success stories. An example is a child with a history of a cancer-related lower limb amputation who presents with pain in the residual limb. The clinician thinks that the pain in the limb is caused by an ill-fitting prosthetic socket because this is what he or she typically sees in their clinic. However, the possibility of a cancer recurrence is not entertained because that is not a common condition in the clinician’s practice.
Recency: This bias is the tendency to emphasize the outcomes of recent diagnoses made or treatments rendered more than ones in the distant past. An example is the successful recent treatment of low back pain in several patients with acupuncture. This success would increase the likelihood that a clinician would use this type of treatment in a new patient presenting with low back pain.
Sunk costs: When a great deal of time, effort, and money is invested in making a diagnosis or rendering a treatment, the clinician is less likely to abandon that diagnosis or treatment if patients are not responding well clinically. An example would be a patient that has undergone joint replacement surgeries of hips and knees and extensive rehabilitative treatments and continues to complain of pain in the legs. The sunk costs are the time, surgery, and cost associated with the patient’s care. Given the extent of the involvement, an alternate possible explanation, such as referred pain from lumbar spinal stenosis, is not given strong consideration.
Anchoring bias: In this bias, a course of action is anchored to a particular diagnosis once it has been made. This bias can be especially problematic when an expert or specialist makes the diagnosis and recommends a certain treatment that becomes a part of the patient’s medical record. Any subsequent contradictory information may be ignored or minimized. Other clinicians may be less likely to challenge that diagnosis and treatment, even though it may be incorrect. An example is when a pain management specialist diagnoses a patient with complex regional pain syndrome in an extremity and all subsequent treatment of the patient’s arm pain is based on that diagnosis, even though there may be contradictory evidence identified by physicians who do not specialize in pain management.
Commission bias: This bias is based on the tendency to favor some type of action rather than inaction and monitoring a situation. This bias may be caused by pressure from patients, colleagues, or the urgency of the situation. An example is when a clinician prescribes opioid medications for chronic pain to a patient who is not an appropriate candidate for this type of medication because of pressure from the patient or his or her primary physician.
Context: The context of the clinical dilemma may be overlooked. An example is attributing a patient’s stroke to noncompliance with antihypertensive medications. However, a closer look reveals a fragmented social support system, limited finances, and impaired decision-making capabilities secondary to prior strokes.
Attribution error: In this type of bias, the doctor’s personal opinion of patients may influence his or her decision making. A negative impression of patients and a wish to end the patient visit quickly may lead to a narrower choice of diagnostic or treatment options and quicker convergence on a particular course of action. A positive impression of patients may lead to a bias in which positive test results are given more weight and diagnoses of serious or life-threatening conditions are minimized. For example, the physician’s false belief that a patient is exhibiting addictive and drug-seeking behavior in a pain clinic may have a negative effect on his or her ability to adequately treat the patient’s pain.
Croskerry described cognitive strategies to reduce diagnostic errors. These strategies include (1) developing an awareness of when a bias is present, (2) considering alternatives, (3) meta-cognition (reflective approach to problem solving), (4) decrease reliance on memory (use of handheld computers, algorithms), (5) develop mental simulation models of biased and nonbiased approaches, (6) provide adequate time to make good decisions, and (7) provide feedback. Some strategies that can be of help in minimizing the effect of cognitive biases in rehabilitation medicine are listed in Appendix 1 .
Patient Safety and Systems Thinking
Systems thinking is a framework for seeing the interrelationships and patterns that lead to events. According to Peter Senge, the essence of systems thinking lies in the following: (1) seeing interrelationships rather than linear cause-and-effect chains, (2) seeing circles of causality, (3) recognizing that events are both cause and effect and nothing is ever influenced in just one direction, and (4) small actions can lead to larger consequences for better or for worse.
In thinking about patient safety, it is important to understand that there can be several causes for a patient injury given the complexity of modern day health care. According to Peter Senge, slow changes and a long incubation period can lead to adverse events in organizations. A problem can occur when health care providers cannot see the consequences of their individual actions in a larger system or over a long period of time. Cause and effect may not be related in time and space. Systems thinking and patient safety is about seeing the whole picture that led to the patient injury and not just the immediate cause. It is important to trace back the roots of a problem outside its immediate area and search for its presence in a larger context.
Rehabilitation medicine, like any other field in medicine, needs investigation into the safety issues specific to this field and needs leaders to spearhead the changes that will improve the safety of patients receiving rehabilitative care.
Barriers, such as delays in the delivery of health care or working around obstacles in the delivery of rehabilitative care instead of addressing them, can have a significant impact on patient safety. Treating the immediate causes of a problem without addressing the fundamental flaws that led to its occurrence in the first place can lead to future patient safety events.
There are several strategies to improve patient safety through systems thinking:
Rehabilitation medicine leaders should create an environment in the rehabilitative setting in which clinicians are in a perpetual state of learning. This environment, which Peter Senge labeled the “ideal learning organization,” encourages (1) different points of view, (2) the evaluation of problems by looking at how events are interconnected, and (3) challenging the status quo. In this environment, clinicians are aware of the gaps in their knowledge base and are constantly challenging themselves to improve the ways in which they deliver rehabilitative care. Rehabilitation managers and supervisors see errors in rehabilitative care as opportunities to learn and improve rather than opportunities to punish. Clinicians are encouraged to seek a deeper understanding of the fundamental causes of events that led to the patient injury in the provision of rehabilitative care. They develop and use a skill set in which they see their actions in a broader context of interrelationships of events.
Constantly evaluate current systems of delivery of rehabilitative care. There are constant changes in the way that rehabilitation is provided in a health care system. These changes could be caused by internal or external influences or both. They may be related to staffing models, level of expertise of rehabilitation clinicians in caring for people with disabilities, financial constraints, and types of disabilities, to name just a few examples. These changes can gradually affect the quality of care being provided and, therefore, systems that may have worked in the past may not be as effective in the present or the future. A constant vigilance for the complexity of the rehabilitative care and a proactive approach to changes that emphasize patient safety and quality is important. Reflection on what works and what does not work and then comparing it with how it should work in an ideal system is an important tool for rehabilitation clinicians. Some common strategies to prevent errors in rehabilitation settings are outlined in Appendix 2 .
Develop a unified belief, culture, and practice among all rehabilitation clinicians that patient safety is a fundamental cornerstone in the provision of rehabilitative services. This development is evidenced in all aspects of rehabilitative practice, such as (1) orientation and mentoring of new staff, (2) diagnosis and patient-specific safety practices in the provision of rehabilitative services in a variety of settings (inpatient, outpatient, and home settings), (3) selection of equipment used in patient care, and (4) continuous attention to quality and patient safety through multidisciplinary reflection, analysis of current practices, and quality improvement.
Plan for failure. Rehabilitation providers should anticipate patient safety failures through constant vigilance and assessment of patient care practices and the environment in which rehabilitative services are provided. They should see what failure looks like and work backward from that potential negative outcome to minimize its risk of occurring in the first place. For example, the admission of a high-fall-risk patient to an inpatient rehabilitation unit should trigger a process in which several team members involved in the patient’s care work in unison to prevent it from happening: The physiatrist would review the medications and eliminate medications that can increase the risk of disorientation and sedation; Rehabilitative nurses can offer the patient prompted toileting before bedtime to reduce the need for the patient to get up in the middle of the night to attempt to go to the bathroom; Physical therapists and occupational therapists can evaluate for environmental risk factors in the patient’s room and in his or her home and provide appropriate training and assistive devices at the patient’s bedside.
In addition to falls, other examples of potential adverse outcomes seen in a rehabilitative setting include (1) contractures, (2) pressure ulcers, and (3) urinary tract infections and aspiration pneumonias. The rehabilitation team should implement strategies that minimize the risk of these adverse events from occurring in the first place but, once they have occurred, should identify strategies that minimize their risk of progression.
A simulated scenario of a potential patient safety event and rehearsal among team members is an effective tool used to foster effective communication in the likelihood that a true event should occur. For example, life-threatening emergencies on inpatient rehabilitation units may not occur frequently; however, when they do occur, it is important that team members communicate and act in a coordinated manner. Team members can rehearse a simulated life-threatening emergency scenario with discussion following the event on areas that went well and areas in need of further improvement.
Conduct constant surveillance of the delivery of rehabilitation services for systems barriers and constraints that can have an adverse effect on patients undergoing rehabilitation and removal of barriers as they arise. For example, changes in staffing levels or expertise coupled with an increase in the number of daily admissions and discharges and a higher diagnostic complexity of patients can all potentially increase the risk of errors in the provision of care to patients admitted to an inpatient rehabilitation unit. One strategy to make managers aware of this trend is to establish internal scorecards that collect this information for review by rehabilitation managers on a regular basis.
Focus on long-term, multidisciplinary solutions for fundamental causes of systems-based problems rather than only on temporary symptomatic solutions and evaluate the potential intended and unintended consequences of the solutions.
Design safe processes. Griffin and Haraden described the development of a “safety conscious culture” in health care organizations. Key elements of this culture include (1) safeguards that take into account the variability in the provision of care by different providers, (2) decreasing the complexity of a process by reducing the number of steps in that process, (3) constantly reviewing a process and eliminating steps that are no longer needed, (4) standardizing processes and minimizing variability because variability can increase the risk for error, (5) equipment should be used that minimizes the reliance on human memory, and (6) safety programs should simultaneously address the prevention, detection, and lessening the risks of injuries.