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Using the GCU Library, locate and summarize an allied health malpractice or negligence case study. If possible, select a case within your chosen field of study. What went wrong? What workplace safety, risk management, and/or quality improvement steps were involved? What could have been done differently? If you were in charge of making sure this type of event never occurred again, what steps would you implement into the risk management plan?
Several things went wrong in this case:
Inadequate Patient Assessment and Documentation: The PT failed to perform a comprehensive assessment, including taking a detailed patient history and vital signs, which would have revealed the patient's high risk for DVT due to her history of smoking and use of oral contraceptives. The PT also didn't properly document the patient's complaints of calf pain and her own clinical findings.
Failure to Recognize a Medical Emergency: The PT failed to recognize a cluster of symptoms (calf pain, fatigue, shortness of breath) that should have raised suspicion for a DVT and subsequent pulmonary embolism.
Lack of Communication: There was a failure to communicate the patient's concerning symptoms to the referring physician.
Inadequate Policies and Training: The physical therapy business owner had few policies and procedures in place and did not provide adequate continuing education for employees on recognizing and managing high-risk conditions.
The case highlights significant gaps in standard safety and risk management protocols.
Workplace Safety: The physical therapy clinic lacked a robust system for clinical safety, specifically for identifying high-risk conditions that may fall outside the typical scope of practice for physical therapists.
Risk Management: There was a critical failure in clinical risk management. A proper risk management plan would have identified the potential for DVT in a patient with an ankle injury and established a clear protocol for screening, documentation, and referral.
Quality Improvement: This event would be a prime candidate for a Root Cause Analysis (RCA). The RCA would reveal that the error wasn't just a single clinician's mistake, but a system-level failure involving inadequate policies, insufficient training, and a lack of a standardized communication process.
The outcome could have been prevented with a few key changes:
The PT should have performed a more thorough patient-history intake to identify risk factors for DVT.
The PT should have halted therapy immediately upon hearing the patient's complaints of calf pain and other symptoms, and referred her back to the physician.
The PT should have meticulously documented all patient complaints, clinical findings, and actions taken, including the decision to refer.
The clinic owner should have had a protocol in place that empowered the PT to stop treatment and mandate an immediate medical referral when signs of a potential emergency were present.
If I were in charge of making sure this type of event never occurred again, I would implement the following steps into the risk management plan:
Standardized DVT Screening Protocol: I would create a mandatory, evidence-based screening tool for all new patients with lower extremity injuries. This protocol would include a comprehensive history for DVT risk factors (e.g., smoking, oral contraceptive use, recent surgery) and a physical assessment that is well-documented. A positive screen would trigger an immediate referral to a physician and a hold on all physical therapy until a DVT is ruled out.
Mandatory Continuing Education: I would institute mandatory, recurring training for all clinical staff on the recognition of life-threatening conditions like DVT and pulmonary embolism, with a specific focus on the signs and symptoms that can present in an outpatient setting. .
Enhanced Interprofessional Communication: I would implement a clear communication protocol, such as a standardized SBAR (Situation, Background, Assessment, Recommendation) form, for physical therapists to use when communicating urgent patient concerns to the referring physician.
Clinical Documentation Audit: I would perform regular audits of patient charts to ensure that all assessments, patient complaints, and risk factor screenings are thoroughly documented. This would help to identify and correct poor documentation habits before they lead to a negative outcome.
A 45-year-old woman was referred to physical therapy (PT) after being diagnosed with a severe ankle sprain. During her initial PT session, she reported persistent calf pain, which she also mentioned on a follow-up appointment two days later. The physical therapist (PT) failed to adequately document the patient's complaints and physical assessment of the calf. The PT also continued with therapy despite the patient's symptoms, which also included increased fatigue and shortness of breath. The patient was found dead in her home two days after her second PT session, with an autopsy revealing the cause of death as a pulmonary embolism stemming from a DVT in her leg.A 45-year-old woman was referred to physical therapy (PT) after being diagnosed with a severe ankle sprain. During her initial PT session, she reported persistent calf pain, which she also mentioned on a follow-up appointment two days later. The physical therapist (PT) failed to adequately document the patient's complaints and physical assessment of the calf.@ The PT also continued with therapy despite the patient's symptoms, which also included increased fatigue and shortness of breath.@ The patient was found dead in her home two days after her second PT session, with an autopsy revealing the cause of death as a pulmonary embolism stemming from a DVT in her leg.