Case of the Month
The Case
The College received a complaint from a patient who attended physiotherapy for pain and loss of strength in their leg and hip. While performing marching exercises at one of their appointments, the patient fell and sustained fractures in their foot.
The patient expressed concerns that the physiotherapist did not prioritize patient safety. The PT didn’t consider the patient’s history of mobility issues and didn’t provide an aid during the exercises.
Additionally, the patient didn’t feel fully supported by the PT after the incident. The patient noted that the physiotherapist and clinic should have better protocols in place for managing adverse events.
The physiotherapist instructed the patient to remain on the floor while they taped the foot. The PT then helped the patient to the treatment table and recommended that the patient have their foot checked by a doctor.
The physiotherapist offered to drive the patient home to get their health card. The PT helped the patient to hop to the car but did not seek help from other staff members at the clinic, even though the patient recalled seeing other staff members available.
The physiotherapist drove the patient home and helped them get in the house. The patient called their spouse before the PT left to return to the clinic. The patient later went to the emergency room where they were referred to the fracture clinic.
The physiotherapist called the patient that evening, while the patient was still in the emergency room. A few days later, the PT had a brief conversation with the patient and the patient confirmed that they were using an air-cast and crutches.
A couple weeks later, the patient called the physiotherapist to express their disappointment that the PT left them alone in their home. They also questioned why nobody from the clinic had asked for their account of the incident to help with documentation.
The physiotherapist did not deny that there were no aids (for example, a wall or support bars) available for the patient during the exercises. Instead, the PT noted that they were positioned close enough to break the patient’s fall, however the incident happened so quickly that the PT was not able to react in time.
The physiotherapist said that they believed they handled the situation appropriately given the circumstances. They also specified that they had already completed some remedial activities like asking for a wheelchair to be made available at the clinic and attending first aid courses.
The Standards
According to the Essential Competency Profile for Physiotherapists in Canada, PTs must ensure the physical safety of their patients by employing safe patient handling techniques, by applying treatment procedures in a way that enhances the patient’s safety and comfort, and by identifying and responding to near misses and adverse events.
When developing a plan for adverse events, PTs can decide what works best for them and their clinic, however patient safety should always be the top priority. A physiotherapist’s written plan should be up to date, personalized to their practice (for example working with people with mobility issues), easy to understand, accessible, and communicated to anyone who might encounter a patient in distress.
The Decision
In reviewing the patient chart, the treatment plan itself seemed clinically sound, however the Committee did identify concerns related to patient safety and care. Notably, the patient had a history of mobility issues and falling, along with weakness in the leg and hip.
At minimum, the physiotherapist should have minimized the risk of the patient falling during the exercises by having an aid available.
Although the physiotherapist did drive the patient home and followed up with them after the incident, the Committee was concerned that the PT did not have an appropriate plan in place for adverse reactions and therefore didn’t know how to handle the situation to the best of their ability.
Because of these concerns, the physiotherapist entered into an agreement with the College to complete a practice enhancement program with a focus on patient safety, working with patients with mobility issues, and managing adverse events.
The Essential Competency Profile for Physiotherapists in Canada
Written Plan for Managing Adverse Events
can u attach some example how written plan for managing adverse event look like?
IS it possible for college to share few more templates on written policy for adverse events like FALL, physio modalities use in Pregnancy.