Patient safety after brain injury: acute medical centers

In the acute trauma setting, several elements must be considered. First, emergency medical service technicians require adequate training in trauma assessment and evaluation with specific consideration for brain injury. For instance, their ability to appropriately document specific medical information related to TBI, such as the Glasgow Coma Scale and loss of consciousness, ultimately assists brain injury specialists to more accurately prognosticate patient recovery. Communication between emergency response staff and emergency department personnel is important in the safe treatment of a patient with TBI. This communication is vital in preparing the team for management of expected injuries, as well as enabling primary trauma teams to have appropriate specialists available at the time of initial hospital evaluation. Effective communication is an overriding theme in the successful implementation of safety culture throughout the health care continuum. According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), almost 70% of all sentinel events are caused by breakdown in communication. It is well documented that effective communication between team members is associated with lessened workloads, improved clinical outcomes, reduced adverse drug events, reduced patient morbidity, and improved job satisfaction and retention, all of which ultimately translate into improved patient safety and satisfaction ( Box 2 ).

Errors leading to a compromise of patient safety may begin in the field and thus alter emergency room evaluation and management. Such errors may include missed or inadequately managed injuries, inadequate or inappropriate use of field medications or stabilization techniques/devices, delay in transport, or transport to a facility not equipped to manage a specific level of injury. In the context of traumatic injury, when multiple systems may be affected and in need of urgent treatment, the ability to effectively triage the injuries is integral to timely and appropriate management. For this purpose, algorithms and clinical care pathways have been established, both in the United States and abroad, to standardize prehospital and in-hospital emergent treatment of traumatic injuries including TBI. Likewise, in an effort to improve patient safety in the emergency room setting, the American College of Emergency Physicians and Centers for Disease Control and Prevention have published specific recommendations for neuroimaging and decision making in individuals with mTBI. Prehospital and in-hospital clinicians rely on accurate history in the diagnosis and management of all patients; unclear histories provided by witnesses, emergency responders, or an obtunded patient can be a cause of medical error. Because of the chaotic environment in which traumatic injuries occur, protocols that outline specific triage and management of these patients can be integral to patient safety by ensuring not only appropriate medical management but also adequate documentation and communication during the course of the trauma evaluation and care delivery. These protocols are unique to each emergency management and hospital system based on available resources but should include, at a minimum, information recommended by national guidelines to effectively manage patients throughout their emergent course and across care continuums.

In addition to establishing hospital-specific protocols, other sources for improvement in patient safety have to be considered. It has been shown that neuroradiologists and neurosurgeons have good inter-rater reliability with regard to diagnosis of brain disorders. However, when these vital personnel are not available for urgent evaluation of clinical imaging, there may be a decline in correct diagnosis of brain disorders. We recommend that institutions providing emergency care have neuroradiologists and neurosurgeons available in the critical first few hours after patient arrival. Misreading of radiological imaging leads to missed disorders, which produces complications such as vasospasm or herniation. Chang and colleagues (2006) showed progression of intracranial lesion within the first 24 hours; therefore, the head computed tomography (CT) should be repeated approximately 24 hours after injury. In the interim, serial neurologic assessment should be used to evaluate for changes.

In the acute medical center, medication reconciliation is paramount in the traumatically brain-injured patient. Medications used in the acute care setting often cause slowing of cognitive recovery. Sedating medications such as opiates, anticholinergics, dopamine blockers, H ₂ blockers and central-acting α-1 antagonists should be avoided, unless there is no other option. In addition, patients with TBI in the ICU setting are often sedated and on ventilators. For these patients, it is important to minimize the risk of pressure wounds by implementing hospital policies that address this specific concern (ie, daily skin evaluation, turning patients every 2 hours, protective dressings). Positioning of patients is also important, because spasticity can start early after injury. Treatment options such as range-of-motion exercises, specialty boots, or bracing can help reduce the development of contractures caused by spasticity. In addition, these patients are at risk for infection, namely pneumonia, urinary tract infection, and intravenous (IV) line infection. Routine evaluation and timely removal of indwelling urinary catheters or IV lines reduce the rate of urinary tract infection and IV line infection. In addition, occult surveillance for fracture, deep vein thrombosis, peripheral nerve injuries, or entrapments should be undertaken because they can be missed on the initial screen when lifesaving treatment is initiated ( Box 3 ).

Patients with TBI often undergo neurosurgical intervention. As part of that intervention, a critical safety factor is the role of anticoagulation. Perioperative anticoagulation has not been studied in a rigorous and prospective fashion. General contraindications to the use of heparin and heparinlike products include recent severe head injury, recent craniotomy, coagulopathic patients, intracranial hemorrhage, bleeding ulcer or other inaccessible bleeding sites, uncontrolled hypertension, severe hepatic or renal disease, and use less than 4 to 6 hours before an invasive procedure. The management of anticoagulation after cranial surgery also does not have specific recommendations; however, our institution uses the following guidelines: (1) no treatment or prophylactic dosing for venous thromboembolism (VTE) on postoperative day (POD) zero; (2) initiation of prophylactic dose, subcutaneous unfractionated heparin on POD 1 to 2, if postoperative head CT is without hemorrhage; (3) repeat head CT to evaluate progress; (4) initiation of therapeutic-dose anticoagulation on day 10 to 14 for known VTE, if no contraindication.

Intracranial hypertension is a common neurologic complication in patients with traumatic head injury. Rangel-Castillo and Robertson detailed the management of intracranial pressure (ICP) in a 2006 review article. Although literature surrounding optimal methods for control of increased cerebral pressure is constantly evolving, it remains one of the most important factors in maintaining patient safety in the acute phase of patient care. Appropriate management of blood glucose can also play a significant role in maintenance of patient safety. Clinical trials support the correlation between hyperglycemia and poor overall outcome in patients with head injuries. Therefore, every effort should be made to maintain euglycemia in individuals with TBI. Fevers, hypotension, and other metabolic abnormalities should be carefully managed in patients with TBI, because these are known to decrease cerebral healing and increase morbidity and mortality in patients with brain injury.

ICUs are places of increased stimulus because of the number of staff, equipment, sounds, and so forth. It is well documented that agitation and delirium can increase in these settings because of the intensity of stimulation. Agitation in the ICU setting can often lead to the use of restraints. One study found restraints were used in more than 48% of patients in the ICU. Because individuals with TBI are often unable to communicate and are at high risk for agitation, there is risk of overuse of mechanical restraints. However, in patients with TBI, the use of restraints can increase agitation, which can lead to a cyclical treatment paradigm. Thus it is best to create guidelines for the use of restraints in each medical setting. Lombard and Zafonte (2005) described mechanisms to reduce agitation in the patient with brain injury in the ICU setting. These mechanisms can be referenced when implementing agitation management plans to reduce the use of restraints.

Medical facilities providing acute patient care for the brain-injured patient should implement educational, multidisciplinary and interdisciplinary committees to establish best practices as appropriate for all staff involved in the management of these patients. Such action aids in increasing and maintaining patient safety and serves to provide open lines of communication should acute medical issues and complications arise.

[Tags: patient safety, acute medical center, emergency department, intensive care unit (ICU), neuroimaging, anticoagulation, intracranial pressure (ICP), agitation].

Patient safety after brain injury: IRF

Just as in the ICU setting, there are many challenges to creating and maintaining an effective and efficient environment of safety on an inpatient rehabilitation unit. Successful patient care and progression through the rehabilitation process requires close coordination and participation by all members of the rehabilitation team, medical and ancillary consultants, as well as family and caregivers. However, the synchronization and mobilization of the large number of interdependent processes and resources needed to sustain an environment of safety on a busy rehabilitation unit are rarely optimal. As such, evolving systems of patient care and care coordination must have a core of patient safety standards and provider accountability to which all members of the rehabilitation team not only adhere but contribute. This unique team approach, although integral to patient recovery, brings with it multiple challenges and increases the probability for error if not closely monitored and actively managed.

The variety of diagnoses present in patients on the inpatient brain injury rehabilitation unit also creates unique challenges. Likewise, constructing a culture of safety in this environment is increasingly difficult because of higher populations of medically complex patients, increasing nurse/patient ratios, and the impetus for shorter rehabilitation stays and cost containment with implementation of prospective reimbursement by diagnosis-related groups. Furthermore, management of life-threatening and limb-threatening medical comorbidities must occur in the context of progressive physical challenges with the ultimate goal of maximizing functional recovery to benefit both medical and financial efficiency. Because of this, therapeutic goals must be closely coordinated to account for medical, functional, and nutritional needs that mandate flexibility during therapeutic progression. This attention and coordination must be in place from admission to discharge, and often well after, to ensure patients successfully transition their recovery to the outpatient setting. An overview of maintaining an environment of safety while addressing the medical and therapeutic challenges involved in the care of inpatient rehabilitation patients with brain injury is presented later.

As mentioned earlier, effective communication as described by the JCAHO is of utmost importance. The IRF is a unique setting that differs from acute and long-term care in the types of clinical issues faced, team composition and interaction, the higher involvement of rehabilitation professionals, and the greater involvement of patients and family members within a patient-centered care model. Communication in this context must effectively flow bidirectionally from clinical therapy staff to patients and family to create a culture of safety that minimizes medical error and maximizes functional recovery. The IRF is often the last step before transitioning home, which builds a need for thorough education of patients and family members in the nuances of TBI rehabilitation and recovery. For example, the level of supervision a patient requires is of utmost importance in early discussion with family members. This discussion facilitates timely disposition and allows preparation of family and caregivers regarding the needs of the patient on return home or other discharge facility.

Inpatients in rehabilitation and their families/caregivers expect that they will not only receive quality health care during their recovery but also that they will not be harmed in the process. However, unavoidable complications do occur, and patients may also be injured because of preventable medical errors. A primary goal of ongoing patient safety is the recognition and timely management of medical errors so that they do not progress to medical injury. Many studies have documented that most morbidity and mortality from medical error is related to the use or misuse of medications and adverse drug events. Although patients in IRFs can be medically and functionally complex, providing more individualized, focused, and hands-on care often affords rehabilitation practitioners the opportunity to monitor more closely for incidents or actions that may lead to medical error. Nevertheless, complications do occur and, although there are no specific data identifying the rates of morbidity and mortality caused by medical error in the IRF, vigilance to decrease the opportunity for error can be fostered by the existing team approach to care. This approach includes universal precautions such as patient identification, checking for drug allergies, medication doses and forms, proper documentation and diligent surveillance of support lines, as well as rehabilitation-specific precautions such as proper use and maintenance of therapy equipment, mobility and orthotic devices (including restraints), dietary restrictions for dysphagic patients, and bowel and bladder management.

Medical errors can occur as isolated events or as the result of a chain of events, the latter becoming more common as more individuals are involved in the delivery of care, as is the case during rehabilitation. Minimizing error, in that human error is impossible to completely eliminate, involves ongoing, evolving, and tiered education so that all members of the rehabilitation team do not only act as an authority in their area of expertise but also as facilitators of information sharing to best meet each individual patient’s needs. As such, it is imperative to have systems in place that not only prevent primary errors (education, proper documentation, organization) but also to prevent secondary errors (coordination or redundancy) by personnel as well as proper use of supplies, electronic and written records, and equipment.

In the IRF, medical errors that adversely affect patient outcomes could occur before admission, especially in the context of polytrauma and/or prolonged hospitalization with complex medical issues or severe debility. As stated earlier in this article, a thorough initial medical assessment and physical documentation is integral to initiating a successful recovery. This assessment includes a comprehensive review of previous diagnoses and interventions as well as review of medications, laboratory values, and radiographs. This task can be daunting, especially if the patient is coming from a noncontiguous facility. Although there are scant published data on delay of diagnoses, the incidence of such could have a great impact on patient safety. For example, fractures, pain, infections, metabolic derangements, nutritional deficiencies, end-organ damage, hydrocephalus, subclinical seizures, blood dyscrasias, and pressure sores are just a few of the things that may go unrecognized or undertreated before rehabilitation. If not recognized and addressed, all of these could affect the patient’s potential for therapeutic participation and progression and, at worst, result in further injury or decline in function. In the setting of TBI, any missed or delayed diagnosis can be exacerbated by the inability of the patient to effectively communicate needs. Also, diseases that are not overtly visible may first present as change in sensorium, including agitation, which can place the patient at greater risk for injury or failure to progress.

Medication management is also integral to therapeutic participation and recovery and includes proper use, delivery, and monitoring. It is estimated that adverse drug events injure or kill more than 770,000 hospitalized patients annually. Although no stratification is made regarding specific incidents during inpatient rehabilitation, the potential for medication mismanagement, especially if the patient is being transferred from an outside facility, is theoretically high. Documentation of drug and other allergies may also be difficult in this context, and the consequences of not knowing that information before initiating certain treatments could be dire. It is common for patients to come to the rehabilitation unit on multiple medications that have been changed in dosage or frequency from their home use or for which they previously had no need. These medications may include sedating medications or as-needed medications that may or may not be indicated once the patient has progressed to a less acute recovery phase. Medication reconciliation using a list of the patient’s prehospital medications, current medications, patient (or family) interview, and, if possible, discussion with the referring medical or surgical service is the best way to prevent medication errors on admission. More than 40% of medication errors are thought to result from inadequate reconciliation in hand-offs during admission, transfer, and discharge of patients. Of these errors, about 20% are thought to result in harm. Many of these errors could be averted if formal medication reconciliation processes were in place. Polypharmacy in individuals with TBI can have dire consequences. For example, patients can suffer from worsening sleep-wake cycle disruption if they are placed on stimulants without understanding why the patient is having difficulty with arousal during the day. Likewise, medication for agitation can mask underlying injury, somatic or visceral pain, or chaining intracranial process. Before adding medications, it is best to evaluate the environment, accurately document the patient’s daily behavior and response to current treatment. It is our recommendation that each brain injury rehabilitation facility formalize a medication reconciliation process to improve patient safety.

Posttraumatic epilepsy (PTE) is a well-recognized complication that generally occurs within 5 years after TBI. The incidence of PTE typically correlates with the severity of injury. Because poorly controlled epilepsy produces medical and social complications and uncontrolled seizures can be fatal, it is integral to patient safety that members of the rehabilitation team are not only familiar with the incidence and associated risk factors for PTE but also have some understanding of the acute and chronic management of seizure disorder. Medical complications caused by PTE are numerous and include alterations in neuronal connections that can lead to further/more severe seizures; aspiration, which can lead to pneumonia; heart rate and blood pressure changes; and disruption of respiratory and body temperature control. Likewise, seizure activity can cause injury through trauma, hyperthermia, hypoxemia, and further neuronal loss, all of which can have a dramatic impact on functional outcome.

Patients also often present to the rehabilitation unit with tracheostomies, gastrointestinal or urologic ostomies and support lines such as peripherally inserted central catheters (PICC), peripheral intravenous catheters, feeding tubes, ports, shunts, fistulas, and urinary catheters. It is important to not only know when these devices were placed, but for what purpose, and to determine whether they need to be monitored, replaced, or discontinued. Medical staff knowledge of specialized medical equipment may also come into play on some specialized units, such as with the delivery of chemotherapeutic agents. Likewise, timely communication with the referring service that may have placed and/or managed the device or line previously is integral to patient safety.

Infection control is a ubiquitous challenge to patient health and safety in the general hospital setting but can be even more so in the IRF. Hospital acquired infections (HAI) have been estimated at approximately 1.7 million per year, resulting in approximately 98,000 deaths, more than 13,000 of these from urinary tract infection alone. HAIs are among the most common adverse events in health care. Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile are two of the most prominent health care–associated infections and represent a major source of avoidable morbidity and mortality. Rates of MRSA isolates as high as 40% have been reported in US hospitals. Patients generally participate in multiple therapies outside their hospital rooms, often in group settings, and using multiuse equipment. Infection control in this environment takes education of staff, patients, and family caregivers of the hospital and unit policy for specific pathogens. Extra care also must be taken to disinfect equipment such as therapy mats, multiuse orthotic devices, and assistive railings that can act as fomites. The community environment of the inpatient unit mandates even closer monitoring of high-risk patients such as those with compromised immune systems, open surgical wounds, or external fixation devices. Coordination of therapy interventions for these patients to avoid infectious transmission relies on effective communication from the medical team and implementation of simple but effective barriers to disease transmission, such as hand washing, proper use of disinfectant foams and gels, and selecting and disposing of appropriate barrier garments. In 2001, Mylotte and colleagues evaluated the frequency of nosocomial infections in 493 consecutive admissions to a university-associated acute rehabilitation unit. They found that the most common infections were urinary tract infection, which accounted for 29.8% of the 94 nosocomial infections, followed by surgical site infection (17%), C difficile diarrhea (15%), and bloodstream infection (12.8%). Overall, 31 (26.5%) of 117 bacterial isolates from nosocomial infections showed antibiotic resistance. Nosocomial bacterial colonization and infection poses a significant health and safety risk to patients in the IRF and prevention requires a multifaceted approach involving everyone from the medical and therapy staff to pharmacy, laboratory, and environmental staff.

Interventional procedures performed on some rehabilitation units also present opportunity for medical error and the compromise of patient safety. Trigger point injections are minimally invasive and can provide focal muscular pain relief that allows improved range of motion and less stressful therapeutic interventions. Although generally safe, complications do occur and proper patient selection should include review of current medications, use of anticoagulants, patient tolerance of needles, and previous procedures. Vasovagal syncope, skin infection, pneumothorax, needle breakage, and hematoma formation are some of the documented adverse events. Spasticity is also commonly seen on the rehabilitation unit after brain injury. Botulinum toxin and, less commonly, phenol injection can be used to lessen the pain and functional burden caused by spasticity. Although generally well tolerated and beneficial, a broad range of adverse outcomes has been reported and should be considered. The safety implications of other invasive procedures that carry their own individual risks must also be considered, such as implanted intrathecal drug delivery system management and refills, PEG, tracheostomy and PICC line removal, pressure ulcer debridement, and suture/staple removal.

The emphasis on increasing patient mobility and independence also presents patient safety risks, especially when the patient has weight-bearing restrictions, delicate wounds, balance deficits, impulsivity, or decreased safety awareness. A patient’s specific mobility challenges must be thoroughly understood by all members of the rehabilitation team to allow consistent and safe delivery of care. Again, communication and documentation are imperative. The most effective strategy for conveying this information is to have a centralized area for documenting functional and mobility limitations. This area can be maintained in the patient’s room or in a staff report area and information should be updated regularly to reflect the patient’s status. Mobility aids must also be regularly evaluated and maintained to ensure patient safety, including patient lifts, transfer aids, wheelchairs, and other power equipment that, if not functioning properly or in disrepair, pose a significant safety risk to patients and staff.

Individuals with TBI often require orthotic devices. These devices, including functional braces and adaptive equipment, can have a significant impact on patient safety if not managed appropriately. Although used for the ultimate goal of improving function and increasing independence, the variety of products available can create a challenge for proper and safe use, especially when the products or equipment can be donned/doffed by medical, nursing, therapy staff, or caregivers not entirely familiar with their use. These products must continually be reassessed for fit, proper use, and need to prevent injury, skin breakdown, or even interference with functional progression.

Preventing falls is a ubiquitous goal across the spectrum of health settings because falls are a leading cause of morbidity and mortality, especially in elderly patients. The range of fall rates in the inpatient rehabilitation patient population has been reported as averaging 8.0 to 19.8 per 1000 bed days, with injury rates in excess of 48%. Risk factors for falls are diverse and include many modifiable entities such as impaired balance, muscle weakness, missing or non–weight-bearing limbs, impulsivity, overuse or underuse of medications, and environmental hazards. The routine use of evidence-based interventions such as the Morse Fall Scale risk assessment, universal and individual fall risk precautions, environment and equipment audits, medication audits, staff training, and patient and family education can result in quantifiable decreases in patient fall risk and, therefore, an increase in overall patient safety.

Unique challenges to medical and functional management are present when working with patients who are minimally or noninteractive; have communication deficits (aphasias or dysarthrias); have cognitive/awareness deficits; or have somnolence, restlessness, combativeness, emotional lability, or attention deficits, to name a few. These patients require an extra level of checks and balances to prevent medication and treatment errors because they are unable to advocate for themselves or reliably direct their own care. In this situation, extra attention must be paid to skin, ostomy, and bowel and bladder issues. This information must be well documented and communicated appropriately to avoid confusion about or failure to deliver an adequate level of care.

Management of patients with brain injury in the IRF can often entail judicious use of physical restraints to prevent patient harm to self, lines, or equipment. These patients often present to the inpatient unit with highly variable fluctuations in agitation, restlessness, and/or poor sleep-wake cycles that can most often be managed with appropriate medications, environmental controls, and timely redirection. These methods are occasionally inadequate to ensure patient safety and some form of physical restraint or monitoring device is required. It is imperative that medical, nursing, and therapy staff be trained in the appropriate use of available restraint and monitoring devices to ensure patient safety and also to facilitate progression through the rehabilitation process. Devices such as bed rail pads, low beds, floor mats, and enclosure beds along with medications are the preferred first-line approach to agitated or restless patients who do not respond to environmental adjustments or redirection. One-to-one or video surveillance supervision is also a viable option if staffing or technology allows. Bed or chair alarms, abdominal binders (to prevent feeding tube manipulation), soft mitts, and soft boots can provide less restrictive protection before consideration of the most restrictive devices such as torso straps or soft wrist restraints. Escalation of restraint type requires constant reassessment of patient needs and daily documentation, and justification for the use of restraints is the best way to ensure appropriate use and patient safety. It is advisable that facility policies incorporate an interdisciplinary approach to the management of agitated patients with brain injury.

Protecting privacy is also a vital component of patient safety. The community environment of the IRF, often with less strict visitation policies and increased patient mobility, creates the opportunity for unintentional lapses in patient privacy. The policy on sharing of patient information must be well known and practiced by all those involved in patient care. Likewise, the patient’s wishes regarding who has access to their medical information must be well documented. Medical and therapy staff must be careful in discussing medical issues in therapy areas or hallways, and patients should be encouraged to request privacy when they have questions about their care, even if that involves waiting until the patient is in a more protected setting.

Appropriate recognition and evaluation of the deterioration of medical or mental status and the timely escalation of care are essential safety standards on the IRF, especially in free-standing rehabilitation units because the proper care may involve physical transfer to an acute medical center. Barriers to escalating care include failure to recognize deterioration, failure to properly investigate medical or mental status changes, and possible difficulty in obtaining specialist involvement or delay in medical testing (STAT laboratories, radiology examinations, and so forth.) Barriers to escalation may also include interpersonal and communication issues in which nurses or therapists are not comfortable presenting their concerns to the medical staff. In academic environments, this could also include the reluctance by house staff to escalate care because of not wanting to seem incompetent or not having the knowledge to know when escalation is needed. All of these situations present a significant safety risk to patients.

Medical, therapy, and ancillary staff education about the unique needs of patients with brain injury is imperative to maintaining an environment of safety. Nursing staff certification training in rehabilitation and brain injury should be encouraged and should include ongoing in-service updates involving the medical, nursing, and therapy staff to ensure not only patient safety but also staff safety. High rates of work injury and illness that create absences from work and discontinuity in patient care are well documented in the health care environment overall. In a 2001 US survey, more than three-quarters of nursing staff reported that unsafe conditions interfered with their ability to deliver high-quality care. Because of the hands-on approach to care required in the IRF, the variety of provider skill sets (nurses, aids, therapists), and the growing use of mobility aids and equipment, the chance for staff injury is increased. Moving and positioning patients creates the potential for staff musculoskeletal injuries that can be reduced by the proper use of lifts and transfer devices. The reduction of this potential also translates directly into the safety of the patient and has been shown to increase the overall satisfaction and sense of security experienced by the patient being moved. Attention to staff safety and its translation to patient safety is an integral part of overall safety culture on a rehabilitation unit. The successful implementation of lifts, adaptive equipment and clothing, and attention to the impact that provider mental and physical health can have on patient care can have far-reaching effects.

In addition, conveying medical and therapeutic information to patients and family is a more complex process than is typically appreciated, and deficiency in addressing this can have a significant impact on patient safety during, and often long after, the inpatient stay. Health literacy and the patient’s and caregiver’s ability to understand and comply with medical and therapeutic recommendations are multifactorial and highly variable but must be considered as an integral part of the rehabilitation process. Factors that can have significant bearing on effective communication in this setting include level of education, language, culture, previous health care experiences, socioeconomics, family/caregiver dynamics, and psychosocial issues. More than 43% of American adults are unable to read, understand, and act on basic health information. This deficiency can be amplified in the patient with brain injury and the family/caregiver’s ability to cope with an injured loved one, especially in the rehabilitation environment when the goal is to transition the patient home, therefore transferring the burden of care from clinical and therapy staff to the caregiver. It is an essential task of the rehabilitation team to actively seek out the medical literacy of the patient and family to ensure effective communication regarding disease states, medications, treatments, and therapies.

Creating and maintaining a culture of safety in the IRF is a formidable undertaking that requires a malleable but solid framework of medical and therapy staff attention and commitment. It is only on a solid foundation that the intricate balance of medical management, therapeutic progress, and care coordination can be successful. Communication, education, shared goals, and effective leadership are the building blocks of that framework.

[Tags: patient safety, inpatient rehabilitation facility (IRF), communication, medical error, medication reconciliation, posttraumatic epilepsy (PTE), infection control, prevention, privacy, education].