Case of the Month
The Case
The College received a complaint from a patient who was burned during physiotherapy treatment.
During the appointment, the physiotherapist placed hot packs onto the patient’s hand and wrist.
Later in the day, after leaving the clinic, the skin on the patient’s hand began to blister and peel.
The Standards
The Risk Management and Safety Standard requires that physiotherapists incorporate appropriate measures to mitigate risks and adhere to safety best practices.
Physiotherapists are also responsible for confirming all equipment and electrophysical modalities are clean, safe, and maintained and calibrated in accordance with manufacturer specifications. Additionally, they must retain documentation of equipment calibration and maintenance.
In this case, the clinic’s safety logs showed the temperature of the device used to heat the hot packs was checked regularly. On the day the patient was burned, the temperature of the device was recorded within the safe range.
The patient record detailed that during the initial assessment, the physiotherapist checked to confirm the patient had hot and cold sensation in their hands.
The physiotherapist said as an additional precaution going forward, they will now perform sensation testing at each appointment before applying heat to a patient.
When a patient safety incident like a burn occurs, physiotherapists must respond immediately to minimize the impact on the patient and document the incident in the clinical record.
In this case, when the patient called to report their skin was blistering, the physiotherapist recommended they seek medical attention if needed and asked permission to follow-up with them by phone later. The physiotherapist documented the incident and informed the clinic manager.
The Outcome
Patients place their trust in physiotherapists when they seek care and should expect to be safe. A patient being hurt during treatment is always a serious matter.
However, in this case the committee determined the physiotherapist followed the standards and guidelines regarding risk management and patient safety, taking reasonable precautions to prevent burns and responding appropriately when the patient was injured.
As a result, the committee decided to take no action.
Details of this case have been changed to maintain anonymity
Patient Safety Resources
Learn how to prevent and respond to patient safety incidents and see templates for incident management plans
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