An Analysis of Adverse Events in the Rehabilitation Department: Using the Veterans Affairs Root Cause Analysis System.

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.