Module 1

The scope of practice of physical therapy is described in the definition

of physical therapy. The APTA's House of Delegates endorsed this
statement in 1983, and it was later changed to include Guide
language.

Physical therapy is a health profession whose main goal is to help

people achieve their best health and function. This goal is achieved by
using scientific concepts to the examination, evaluation, diagnosis,
prognosis, and intervention processes in order to prevent or treat
impairments, functional restrictions, and disabilities in mobility and
health.

Ancient civilizations relied on physical techniques to alleviate pain and

increase function. Massage was first employed by the Chinese around
3000 B.C., was first recorded by Hippocrates in 460 B.C., was later
refined by the Romans, and was finally recognized as a scientific
process in the early 1800s. Muscle reeducation techniques arose as a
result of this development. The Greeks and Romans practiced
hydrotherapy through the use of baths and river worship. With the
arrival of electricity and electrical instruments in the 1600s,
electrotherapy began to take shape.

Before being used in the United States, more sophisticated physical

therapy procedures were widely used in Europe, particularly in
England and France.

Physical Therapist Criteria

Lifetime Commitment
Representative Organization
Specialized Education
Service to Clients
Autonomy of Judgement

The Division of Special Hospitals and Physical Reconstruction was

established in in order to train and manage reconstruction aids (all of
whom were women) who would give physical reconstruction to war
victims. These ladies paved the way for physical therapy as a
profession and practice in the United States.

The first level of care, primary care, is described as health care

provided by a member of the health-care system who is accountable
for the individual's majority of health-care needs. This level of care is
normally delivered by the first health care provider who comes into
touch with the recipient, but it is not always the case. At this level,
family and community members may also give care. Clinicians give
secondary care following primary care, that is, after the individual has
undergone primary care. Specialists provide tertiary care, which is
usually given in facilities that specialize in certain health concerns.
These services may also be offered as a result of a recommendation.

Physical therapists work at all three levels of care. Physical therapy is

frequently provided as secondary or tertiary care after a referral. A
highly specialized unit, such as a burn care facility, may provide
tertiary care. However, primary care is becoming the new entry point
for people seeking physical therapy services. Direct access is the term
used to describe this situation. The term "direct access" is chosen
over "practice without reference," which implies that practitioners in

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other disciplines are uninterested in the vital services they provide. In
this capacity, the PT acts as a gatekeeper for additional health-care
services.

Physical therapists assess each individual and devise a treatment

plan to help them move better, manage pain, regain function, and
avoid disability. Physical therapists have the ability to make a
significant difference in people's lives.

Chronic musculoskeletal diseases, for example, might be difficult to

treat. Others, like Parkinson's disease, are incurable. It's critical for
both you and your patients that you be realistic about patient
outcomes and don't set or foster false expectations in your patients.

When working with difficult patients, it's critical to be patient with the
therapy process and to remain calm and composed. Treatment times
are determined not only by the patient's medical state, but also by
their motivation, physical capabilities, and other factors.

Even if it's in a virtual setting, the finest physical therapists understand

the need of teamwork. You and your patients are on the same team,
and their PT goals should be the same in the end. Encourage open
communication and always consider what your patients and peers
have to say. Develop a collaborative approach when it comes to
working with your PT and other healthcare staff. Interprofessional
collaboration enhances patient satisfaction ratings and health
outcomes, and working on a team with others is a terrific opportunity
to learn and grow.

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As a physical therapist, you must be willing to take on difficult patients
while remaining motivated. Even when patients want to give up, it's
critical that you stay focused on the process, encourage them to keep
working, and remain committed to assisting them in their recovery.

Resilience is a crucial attribute in a physical therapist. Physical

therapy treatment, like most things in life, does not follow a straight
line; your patients will most certainly go through ups and downs. A
resilient physical therapist can adjust to change and even thrive in the
face of hardship.

You must have compassion in order to work in patient care. Patients

may be fearful of the therapy procedure; therefore, empathy and a
pleasant bedside manner are essential in making them feel at ease
and ready to work. An effective physical therapist is concerned about
their patients' well-being. They also ask the correct questions to figure
out what the most significant therapy goals are for each patient.

Physical therapists help people with a variety of ailments, ranging from

joint injuries to neurological illnesses. Even if you eventually decide to
specialize in a certain field, such as geriatrics or cancer, as a PT, you
must be able to draw on a wealth of expertise. A excellent physical
therapist is always reviewing new developments and best practices in
the industry and staying current with them.

It's critical not only to be upfront and honest with your patients, but
also to follow through on your promises. Integrity aids in the
development of a healthy, trust-based connection between you and
your patients. Excellent physical therapists are always professional
and have strong ethical standards, such as respecting patients'
privacy and always acting in their best interests.

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Patients' wishes are respected by good physical therapists. Your
patients will decide whether or not to pursue the treatment alternatives
you recommend, regardless of what you believe to be the best course
of action. You are free to express your professional opinion, but you
must ultimately accept the patient's decision. You'll see patients of
various ages and body kinds, from all walks of life, in your therapy
practice. It's critical to treat your patients with respect.

You'll talk with your patient about their acute symptoms, as well as
their present and desired levels of fitness and health, before
evaluating them and devising a treatment plan. A patient who knows
their care plan is more likely to succeed, therefore being able to
communicate effectively is a crucial part of your job. PTs should strive
to educate patients in plain language and ask probing questions to
learn about their needs so that communication can flow both ways.

You'll be able to spot any changes in the patient's ability if you pay
great attention to the details. Because individuals with the same injury
can respond to treatment differently, it's critical to keep a careful eye
on each patient's development and change your care plan as needed,
regardless of your personal expectations. Maintaining your wits about
you will aid you in determining the patient's particular and changing
needs.

Working with people who are in pain, if not outright suffering, can be
draining emotionally. As a physical therapist, you should be able to
maintain a cheerful, enthusiastic, and open-minded attitude. Learning
to turn negatives into positives as much as possible and combating
negative self-talk will help you achieve in the long run.

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Module 2

The caregiver may need to guide, direct, or instruct each patient. For
many patients, a brief demonstration of an activity or the use of
equipment by the caregiver or another person may enable the patient
to better understand. Verbal communication, written communication,
and nonverbal communication (NVC) among the caregiver, the
patient, and family members are necessary. The purpose of each
activity, its expected outcome, and the method of performance should
be explained to the patient

No activity should be attempted unless sufficient personnel and

equipment are available to accomplish the task safely. All persons
who assist with the patient's care must be trained and competent; the
equipment must function properly and be safe and stable; and the
patient must be evaluated to determine the capacity to assist with or
perform a particular activity. Patient examination and evaluation,
patient safety, and communication between the caregiver and the
patient are required to promote high-quality patient care. Lack of
attention to any one of these areas can adversely affect the quality of
care the patient receives

Many organizations use a team of caregivers from different

professions who review a patient's condition, determine the problems
amenable to treatment, discuss potential treatment solutions, and
make decisions to resolve problems. This interprofessional
collaboration approach is particularly useful for patients with complex
medical, social, economic, or other problems. To be successful,
interprofessional collaboration requires periodic team meetings to
solve problems and reach decisions about management of the patient.
Collaboration, coordination, and communication are important factors
used by the team to help the patient effectively fulfill goals or needs

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The interprofessional team approach must be patient centered rather
than profession centered. Team members must be able to provide
advice, counsel, and recommendations based on each member's
knowledge and expertise that will lead to the best outcome for the
patient. Group members need to be adept in the application of group
process skills; thus, it is recommended that a portion of their formal
education be devoted to an introduction to and practice of techniques,
skills, and activities associated with group interaction

Another concept used in patient care is professional teamwork or,

more specifically, co-treatment. This method of treatment is
particularly important for professions that have levels or types of
caregivers. Examples are a physician and physician assistant in the
medical profession, a registered nurse and licensed practical nurse or
nurse aide in the nursing profession, an occupational therapist (OT)
and occupational therapy assistant (COTA) in the occupational
therapy profession, and a physical therapist (PT) and physical therapy
assistant (PTA) in the physical therapy profession

An ideal relationship exists when the two caregivers co-treat the

patient. In such a relationship, two persons cooperatively establish the
activities each will perform. The primary caregiver evaluates the
patient, provides a plan of care, determines the treatments to be used,
assigns tasks and responsibilities for the assistant to follow,
establishes the goals or desired outcomes of treatment, and
periodically evaluates the results of the treatment and the patient's
responses to the treatment. The assistant performs the treatment
activities and communicates frequently, verbally and in writing, with
the primary caregiver. Changes in the patient's condition, outcomes of
the treatments used, and observations by the assistant help the
primary caregiver alter or adjust the plan of care. The primary

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caregiver eventually performs the activities necessary to terminate the
treatment and discharge the patient from services

It is imperative that the primary caregiver be aware of the activities of

the assistant and that the assistant understand the rationale for the
treatment and inform the primary caregiver of the patient's response

Before seeing the patient, the caregiver should perform a

comprehensive review of the patient's medical record including the
physician's notes on the medical history, current history, physical
findings, and diagnosis; test results; the physician request for
treatment; nursing notes; medications prescribed; and any
consultations to other medical/surgical specialties

Introduce yourself by name and title or professional designation.

Verify the patient you are treating, using at least two patient identifiers
such as patient name, medical record number, date of birth, or driver's
license.
Verify or confirm patient information you have received such as name,
diagnosis, purpose of treatment, and referral source.
Interview the patient to obtain relevant information; be alert for
culturally different norms or traditions
Perform assessment, examination, and evaluation activities to
establish the patient's capabilities, condition, problems, needs, goals,
and clinical diagnosis.
Establish treatment goals and functional outcomes with patient input.
Inform the patient of the treatment plan and techniques selected to
fulfill outcome goals; include information about risks or adverse effects
associated with the treatment.

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Encourage the patient to ask questions to enable the person to
consent to or decline treatment.
Request that the patient sign an informed consent document or record
the oral consent in the medical record

In some states, PTs can evaluate or treat without a physician's

referral. In this case, the PT must be diligent in completing a
comprehensive history and be open to referring the patient to a
physician if the PT's findings warrant this. Red flag warnings during
evaluation or treatment indicate that the patient should be referred to a
physician immediately

Caregivers are more likely today to treat patients with cultural or

religious foundations that vary greatly from their own. In preparation,
the caregiver should be aware of his or her own personal biases,
prejudices, attitudes, and values to better understand the effect these
beliefs may have on a patient if they are applied injudiciously. The
caregiver should learn about or research the cultural norms and
traditions associated with different ethnic or religious groups before
treatment to be able to exhibit desirable behavior toward those
individuals and their family members. Differences in language (verbal
and nonverbal), cultural or religious norms or traditions, and personal
bias or prejudice can create problems between the caregiver and the
patient

Understanding the cultural norms of a patient can help the caregiver

enhance the effectiveness of the treatment by improving
communication and developing respect between the two individuals

The words used and the actions exhibited should convey respect for
differences in the age, gender, race or ethnicity, abilities, and sexual

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orientation of each person. Only a few examples of cultural or religious
norms or traditions have been presented. The US Department of
Justice's Americans With Disabilities Act of 1990 and the Civil Rights
Act of 1964 protect many cultural rights. In addition, these or similar
rights may be contained in institutional personnel policies, patient
rights statements, and government documents

The Health Insurance Portability and Accountability Act of 1996

(HIPAA), a federal law enacted to protect health care–related
information. The HIPAA Privacy Rule protects all “individually
identifiable health information” held or transmitted by a covered entity
or its business associate, in any form or media, whether electronic,
oral, or on paper

Violations of the Privacy Rule include sharing or discussing protected

health information with other health care workers who are not involved
in the care of the patient; accessing patient information when not
involved in the patient's care (e.g., looking up information in the chart
of a coworker, friend, or family member); and not providing a patient
with access to his or her medical record within 30 days of the patient's
request for such information

An Advance Health Care Directive, also known as a “living will,” is a

set of instructions to give an appointed individual the right to make
decisions concerning the health care actions to be taken when a
person is no longer able to make decisions because of illness or
incapacity. A standard advance directive form provides room to state
additional wishes and instructions regarding organ donations

A living will, which becomes effective only under the circumstances

delineated in the document, is one form of advance directive that

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provides instructions for treatment. It is the oldest form of advance
directive and was first proposed by an Illinois attorney, Luis Kutner, in
the Indiana Law Journal in 1969

Typically, before a living will is implemented, two physicians must

verify that the patient is incapable of making medical decisions and
that his or her condition is in compliance with the state's living will law.
If a person's condition changes such that he or she regains the ability
to make decisions, the living will is no longer in effect. Appointing a
power of attorney or health care proxy is another form of advance
directive. A power of attorney or health care proxy allows the patient to
designate a person to make decisions on behalf of the patient in the
event that the patient is physically unable to make the decision

When obtaining informed consent, the more information provided by a

caregiver about benefits of therapy, the alternatives, anticipated time
frames, cost, and risks, the less likely it is that the caregiver will be
held liable if a patient claims that the caregiver failed to provide
adequate information. Before the initial treatment of a patient, the
caregiver is responsible for informing the person about the proposed
treatment, alternative treatments that are available, and associated
primary known risks. The patient then has the right to consent to or
reject the proposed treatment. This process is the process of informed
consent

To ensure that the patient is properly informed, the caregiver must

provide sufficient information about the proposed treatment and any
alternative treatment appropriate for the person's condition to permit
the person to arrive at an intelligent and knowledgeable decision. The
patient must be able to understand the information. Therefore, it must
be presented using terms and language that are comprehensible to
the patient. A translator or an interpreter may be required for persons

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who do not speak or comprehend English. If a family member agrees
to interpret for the patient, this accommodation should be documented
in the medical record. Many health care facilities use an interpreter
telephone service to meet the needs of patients who do not speak or
understand English

The documentation of patient care is an important component of the

written record maintained for each patient. Physicians, nurses,
therapists, social workers, and many other persons involved with
providing patient care perform documentation, which assists in better
treatment planning and improved communication among disciplines.
Documentation is closely scrutinized by funding sources to determine
payment or denial of services

The following areas also should be considered for therapy

documentation:
1. The patient's primary and treatment diagnosis
2. Physician's orders
3. The patient's barriers to treatment and their resolution
4. The patient's consent to treatment
5. The plan of care, which includes goals, treatments, proposed
frequency and duration, and discharge
6. Short-term and long-term goals
7. Risk or benefit of treatment

Electronic home exercise programs are now available to clinicians.

These modifiable programs can be individualized for each patient. The
patient can log onto a website, complete the home exercise program,
and compliance and successful completion are documented.

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Lawrence Weed developed the concept of the problem-oriented
medical record (POMR) in the 1960s. This system is used by many
health care facilities throughout the United States, some of which have
developed their own variations. This system is based on a list of
patient problems; a database; and a series of status (progress) notes
designated as “initial,” “interim or ongoing,” and “discharge” notes.
When all departments or service units of a facility use a POMR, a
higher quality of patient care may be anticipated, better
communication among the caregivers is more likely to occur, and
better decisions about the patient's treatment can be made.
Information about the patient and the plan of care is contained in the
status notes, which are written in the SOAP format: subjective,
objective, assessment, and plan

1. Formation of a database (current and past information about the

patient)
2. Development of a specific, current problem list (problems to be
treated by various practitioners)
3. Identification of a specific treatment plan (developed by each
caregiver)
4. Assessment of treatment plan effectiveness

Document every encounter/visit.

Documentation must comply with regulatory requirements.
Documentation must include identification of the patient and the PT or
the PT assistant (or student where permitted by state and/or facility
regulations).
The patient's full name and identification number (if applicable) must
be included on all official documents

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Documentation should indicate the referral source (physician or other
practitioner, self-referral/direct access)
All entries must be dated and signed with the PT's full name and title
Avoid general statements and provide specific, concise, clarifying
information. Instead of stating “The patient is uncooperative,” state
“The patient refused to perform active assistive exercise”
Use objective statements; instead of stating “Patient ambulates,” state
“Patient ambulates 25 feet in 1 minute using bilateral axillary crutches
on a level surface, with assistance, using a 3-point pattern for 3
repetitions, with a 5-minute rest period between ambulations.”
Functional outcome measure statements more accurately describe the
patient's condition and assist with obtaining reimbursement
Be complete with your statements; record the significant or important
information about the patient's condition, progress, or response to
treatment. Remember, if an activity is not documented, it may be
considered as not having occurred. If an unusual activity or procedure
is used, document why it was selected and used. Unusual incidents,
the action taken afterward, and an objective description of the
patient's condition or reaction should be recorded, dated, and timed.
An incident report should be filed with the risk manager or similar
individual, and it may be necessary to document that it was prepared
and filed
Provide continuity with your status (i.e., progress) notes. Be certain to
indicate why or how you reached a particular decision about the care
or treatment you provided, especially if it deviated from the acceptable
care or treatment.
Programs or treatment plans designed for the patient to follow at
home should be well documented and include precautions. Your
documentation should indicate how you determined (or the steps
taken to ensure) the patient or family member understood and could
comply with the instructions.

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 Identify that you informed the patient of the treatment to be provided
and its risks or hazards, that the patient understood the information,
and that consent to treatment was given. If a service unit uses a
consent form, a copy signed by the patient should be in the medical
record.
Be prompt and timely with your entries, and write legibly. Be certain
the information is accurate and consistent between entries. Investigate
and clarify contradictory information; for example, is it the right hip or
the left hip that requires treatment?
Use only abbreviations that have been standardized or accepted and
approved by the facility or the profession

Be certain there are no empty or open lines between entries and there
are no open spaces within the notes. Use the format approved by the
human information systems department or used by the facility or
profession.
Outline the major elements of the notes in your mind or on paper
before you enter them in the record to avoid having to make a
correction or a change in the notes. Avoid omissions, such as the date
of initial or subsequent treatments, a change in treatment, or a
discharge summary.
Properly countersign the entries of other persons according to state
statutes and facility requirements. Read the entry before
countersigning it; it is prudent to review the proposed entry to ensure
that it is accurate and complete before it is placed in the record

The following standard procedures should be followed when

correcting a note in a handwritten medical record:
Draw a single line through the inaccurate information, maintaining
legibility

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Date and initial the correction
Enter the corrected statement in the chronologic sequence of the
record, and ensure it is clear which entry the correction replaces.
Use black ink for all corrections and entries

In some situations, it may be beneficial to have the corrected

statement witnessed by a colleague. Avoid alterations that create the
appearance of tampering (e.g., erasing or writing over a word or
phrase to improve legibility). Material in the record should never be
obliterated or covered up. Improper alteration of an entry can create
many problems for the practitioner if the entry is questioned or used
as evidence during litigation. The practitioner's credibility, honesty,
and intent will be challenged, which may lead to charges of
incompetence, negligent behavior, or poor judgment. Many errors of
judgment are not negligent acts, but any attempt to hide them can
create serious problems. Never enter a note or sign an entry for
someone else, and do not ask someone else to perform such acts for
you

Documentation acts as a means to assess or measure the quality of

care received by the patient so that the caregiver or facility will be
more likely to receive payment from a third-party payer. Persons who
review claims and make reimbursement and treatment-related
decisions focus on indicators of functional outcomes of treatment
contained in the caregiver's documentation. Therefore, the caregiver
must provide accurate, current, function-oriented documentation. In
addition, the use of function-oriented, objective, and measurable data
in the documentation process will result in the greatest likelihood of
obtaining a favorable reimbursement response to submitted claims
and gaining approval to continue treatment from the third-party payer.
It seems reasonable to anticipate that a patient will have more
motivation to accomplish a functional goal or task that is meaningful

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than to strive to attain a given strength or range-of-motion value. In
addition, well-organized, accurate, relevant, and prompt
documentation improves communication among all persons providing
care

The patient should be informed of the findings or results of the

examination and evaluation and should assist with the development of
the goals and outcomes of the treatment. The patient's emotional
response or reaction to the condition, family interactions, available
support system, potential for improvement or regression of the
condition, and goals or expectations of the person should be
considered. Goals of treatment should be established cooperatively
between the patient and the caregiver. These goals usually are
designated as interim (or short-term) and terminal (or long-term).
Short-term goals are usually a specific component or leading activity
for a long-term goal

The public continues to demonstrate an interest in and desire to

become better informed about medical and health care in general and
about the specific medical and health care that individuals receive.
Patients and family members expect to be consulted and informed
about the care they receive. Questions related to the need for, efficacy
of, and expected results or outcome of treatment are routinely asked.
The practitioner must be prepared to provide appropriate and accurate
responses without expressing or implying a guarantee or promise that
a specific outcome or result will be achieved. The patient must be
informed, with language and terminology that is understandable, about
the treatment to be received so that an informed decision about its
value and safety can be made

Communication among people is a primary function of life. For the

caregiver, communication with patients, family members, other

17
practitioners, and coworkers is a necessity. The caregiver should
recognize that different forms of communication such as verbal
communication, NVC, and attentive listening may be required
depending on the purpose or situation related to the communication.
Various barriers to communication should be recognized,
documented, and avoided whenever possible. Patient-caregiver
rapport can quickly be established by effective communication or
delayed by the lack of it

When verbal communication is used, terms and concepts should be

presented in language that the listener understands. Lay language is
the most useful for most patients and family members. For example,
“bend” is better than “flex,” “turn” or “twist” is better than “rotate,” and
“straighten” is better than “extend” when instructing the patient or
family. Directions should guide the patient to act and should be brief
and concise. Functional terms or phrases such as “push,” “stand,”
“sit,” “turn toward me,” and “reach to the left” are more effective than
nonfunctional phrases such as “Now, the first thing I want you to do is
…” or “The next thing I want you to do is ….” However, it is necessary
to provide some transitional terms and phrases, such as “Push with
your hands on the armrests,” “Straighten your hips and knees,” or
“Move your right crutch and left leg forward.” The patient should be
given time to process the message. The time required for processing
varies from person to person

Excessive distance between the sender and receiver decreases

effectiveness
Noise and environmental confusion interfere with and may distort the
message
The receiver may be unable to comprehend the message

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The receiver may be unable to interpret or understand technical,
medical, and professional terms, language, or abbreviations
There is an inadequate amount of feedback between the receiver and
sender
Complex messages may be difficult to interpret and comprehend
The sender and receiver may interpret the message differently
Cultural, gender, or age differences between the sender and receiver
may affect the interpretation or comprehension of the message
Illegible writing affects the accuracy and comprehension of the
message

Caregivers must be aware of their responsibility to communicate

appropriately with a person with an impairment. First and foremost,
maintain the person's self esteem by considering the person first in
your words and thoughts. The person's health condition should be
described accurately if it needs to be included in the message, but it is
more important to emphasize the person's abilities rather than his or
her impairment. For example, the statement “John, who has a spinal
cord injury, uses a wheelchair for mobility” is more appropriate than
“Because he has a broken back, John is confined to a wheelchair.”
The use of the term “person with an impairment” is preferable to the
term “disabled person” to promote the person's self-esteem and
recognition as a person first

Interact directly with the person with the impairment

Greet the person with respect as you would a person without an
impairment; shake hands or forearm, or use your left hand as
appropriate
Identify yourself and other persons in a group to a person who is
visually impaired

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Stoop or squat to communicate with a person in a wheelchair; position
yourself in front and at eye level
Avoid leaning or sitting on a person's wheelchair; use care when
handling assistive aids
Avoid statements, gestures, or actions that patronize; interact as you
would with persons who do not have impairment
Tactilely or visually cue a person who is hearing impaired to indicate
your presence
Be patient and listen carefully when interacting with a person who has
difficulty speaking; use questions that require brief responses
Determine whether the person desires assistance before assisting him
or her; wait for instructions

When you communicate with a person who has difficulty speaking,

intensify your listening skills and provide feedback to the individual to
indicate your understanding of the message. Avoid correcting,
interrupting, anticipating what the person will say, or speaking for him
or her. Be patient during the conversation, and wait for confirmation of
your feedback before continuing. The use of questions that require
brief responses or that can be answered by a head nod or shake may
assist this person. Sometimes you may sense that a person with an
activity limitation may require assistance to perform a task or activity.
When this occurs, you should ask the person whether assistance is
desired and, if it is desired, ask for specific instructions or directions

In hospitals worldwide, a list of emergency codes is used to alert staff

to various emergency situations. The use of codes is intended to
convey crucial information quickly and with a minimum of
misunderstanding to staff, while preventing panic or stress among
visitors to the hospital. These codes may be printed on staff
identification badges for ready reference or posted on placards

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throughout the hospital. A person calling a code should give the
location of the emergency. Hospital emergency codes are commonly
coded by color, and the color codes denote different events at
different hospitals

Code red = fire

Code blue = heart or respiratory arrest
Code orange = hazardous material spill or release
Code gray = combative person
Code silver = person with weapon/hostage situation
Amber alert = infant and child abduction
External triage = external disaster
Internal triage = internal emergency
Rapid response team = rapid response team
Code name clear = to clear a code

Medical errors still occur with some frequency and have resulted in
thousands of injuries or deaths. Medical errors occur when a planned
treatment does not work as it was intended or when an improper
treatment is used

According to The Joint Commission, medical errors fall into two of four
categories: sentinel (adverse) or potential adverse event and active or
latent error

The primary types of medical errors result from errors in medication

prescriptions or regimens, surgical procedures, diagnostic or
laboratory report inaccuracies, and practice mistakes. Caregivers

21
should realize that the potential always exists for a medication error to
occur. A medication error is one of the most common types of error
and is a primary concern for the person who prescribes (physician),
dispenses (pharmacist), and administers (nurse or therapist) the
medication

1. Right patient
2. Right drug
3. Right time
4. Right route
5. Right dose

Several factors may be at play in medical errors, as follows:

The complexity of the health care delivery system
The number of caregivers involved in the patient's care
Improper or faulty installation and maintenance of equipment
Flaws in the design of systems, equipment, or organizational structure

Safety Recommendations
Perform hand hygiene before and after treating each patient to reduce
crosscontamination and transmission of disease; this is the most
important activity to prevent the spread of infection.
Maintain sufficient space to maneuver equipment or perform a task;
store equipment that is not in use so that it will not interfere with
patient care; position a patient to avoid the risk of being struck by
passing personnel or equipment.

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Do not perform transfers or ambulation in an area where your view is
obstructed, such as near a door or the corner of a hallway, or where
space is inadequate or too congested for the activity.
Routinely evaluate equipment to ensure it functions properly; establish
a maintenance program for each item.
Position equipment, furniture, and assistive aids so that the items are
stable, secure, and accessible when they are used; remove them
when they are not in use so that they do not interfere with patient and
caregiver movements.
Keep the floor clear of electrical cords, litter, loose rugs or floor mats,
water, dirt, and other similar hazards.
Do not leave patients unattended, especially if they are compromised
physiologically or cognitively.
Protect the patient with safety straps, bed rails, or similar items when
they are not closely attended, according to established agency,
regulatory body, and state or federal restrictions and guidelines.
Obtain the equipment and supplies needed, and prepare the treatment
area before the patient arrives to avoid the need to leave the patient
unattended
Be certain the personnel who provide patient care are trained,
qualified, and competent in their assigned duties.
Avoid storing potentially hazardous equipment or materials in a
location where they are hidden from view or where there is a risk of a
patient obtaining them; do not store chemicals or heavy objects on a
shelf above shoulder level; clearly label the contents and weight of
boxes or other containers.

Errors in diagnosis by the caregiver can occur when the examination

is not thorough enough. An example would be when a patient with a
medical diagnosis of stroke reports arm pain, and the therapist must

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determine whether it is from musculoskeletal or neurologic causes. If
the therapist determines the cause of the pain incorrectly, treatment
may be ineffective and lead to an unsatisfactory outcome. Another
example would be a situation in which a patient reports pain from a
headache, and the therapist determines that it is a cervical
musculoskeletal problem when actually it is a neurologic problem

Treatment errors occur when the chosen treatment is of no help or is

harmful to the patient. The therapist may choose a technique or
modality that is incorrect for the injury; provide too little treatment with
an inadequate patient response; provide excessive treatment, causing
a physiologic response that is too intense and may cause further harm
or increased pain; or apply the technique incorrectly.
Failure in communication can cause serious negative results in the
patient's care. The patient's medical information must remain
confidential; at the same time, the need to communicate important
patient information with appropriate caregivers is crucial to the
patient's care. Examples of communication errors include improper or
inadequate documentation and not asking the correct questions of the
patient. Lack of communication within the therapy care team also may
result in a medical error

The Joint Commission surveys examine the following areas: Ethics,

Rights, Responsibility, and Provision of Care
Medication Management; Environment of Care
Surveillance, Prevention, and Control of Infection; Leadership
Improving Organizational Performance; Management of the
Environment of Care
Management of Human Resources; Management of Information
Medical Staff Co-Leaders; Nursing National Patient Safety
Goals/Sentinel Event

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The Joint Commission standards dictate that a health care
organization must perform the following tasks to keep its patients safe
from medical errors:
Assess its own compliance with all applicable standards, national
patient safety goals, and accreditation participation requirements
Create plans of action to bring noncompliant standards into
compliance and identify ways to measure the success of those plans
Interact in a phone call with The Joint Commission staff to review and
receive approval of plans of action and applicable measures of
success
Implement the plans to bring all standards and accreditation
participation requirements into compliance
Demonstrate a 12-month track record for all plans of action at the
time of the triennial survey

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