**5. Potential errors: from minor to major consequences**

Most in-hospital care have a strong safety culture in which the different components and layers of patient safety are strongly embedded in both medical and nursing practice [61], probably because working in these settings carries more risks as it involves more invasive and complex techniques and procedures. In physiotherapy, by contrast, AEs are generally classified as minor (no-harm) events or near misses (incidents that do not cause harm to the patient) [42]. Examples are interference with equipment or devices during mobilization of a critically ill patient, a mild burn sustained during heat therapy, or a near fall when transferring a patient from one chair to another. Interprofessional and multiprofessional collaboration is also at a more nascent stage in physiotherapy than in medicine, where the doctor/nurse tandem is well established [61].

Although no-harm and near-miss events may be anywhere between 7 and 100 times more common than AEs, systems for reporting them are much less common [62]. These less-impactful events represent latent system risks that must be reported to prevent serious consequences in the future [63]. High incidence rates have been reported for these events in physiotherapy, but the fact that they cause few consequences has probably contributed to general perception of physiotherapy care being harmless [50].

Invasive procedures, such as dry needling, however, are becoming more common in physiotherapy and certain rehabilitation treatments with the potential to cause serious AEs (e.g., early rehabilitation of orthopedic surgery patients, respiratory and neuromuscular physiotherapy in intensive care patients, and manual treatment of spinal cord injuries) are already in wide use [32, 51]. Incorrect mobilization after prosthetic orthopedic surgery can undo the results of surgery [52], while detailed knowledge and extreme care are needed when delivering treatment to a critically ill patient whose life depends on certain machines or devices (e.g., respirators, intravascular catheters, or hemodialysis machines) [32, 53]. Patients in intensive care units or orthopedic departments after surgery require specialized and highly protocolized care. In such environments, the therapeutic development of physiotherapy will be safe as long as the patient safety culture is well established. Recommendations in those fields need to be more extensively practiced and researched to deepen the discussion.

To manage the risks associated with a given treatment, one must not only be aware that they exist but also understand their severity (see example in **Figure 3**) and potential impact. Such an awareness will favor the reporting of incidents by both physiotherapists and other agents [64].

Analyses of risk prevention should also incentivize reporting [9]. Research in physiotherapy has been increasing in recent decades. This means that more and more information is available on the effectiveness of the applied treatments. Information is also available on their risks. Creating this scientific awareness should, little by little, help to also build an awareness of patient safety, which inevitably includes proper reporting. The notification of incidents and adverse effects has been essential to implement prevention strategies in medicine or nursing. Without knowing what is really happening and the associated factors, it is not possible to apply effective measures. The SdP culture, which is not based on searching for the guilty professional but on the human factor and the organization of the system, has encouraged the communication of incidents and adverse effects, therefore their analysis and prevention. In physical therapy, the same process of encouraging communication should be applied. AEs associated with physiotherapy is sometimes reported by other health care professionals, such as emergency department doctors. The problem in such cases

*Patient Safety in Physiotherapy: Are Errors that Cause or Could Cause Harm Preventable? DOI: http://dx.doi.org/10.5772/intechopen.107847*

#### **Figure 3.**

*Continuum of error occurrence with examples from the physiotherapy field. Adapted from Ginsburg et al. [64].*

is that reports will probably be incomplete as the attending doctor may not be aware of the patient's history (i.e., the link with physiotherapy) and will not conduct a full root-cause analysis [50].

There is a direct link between the trivialization of possible adverse treatment outcomes and underreporting of errors. Viewing a physiotherapy intervention with inherent risks (however slight) as safe jeopardizes professional autonomy and selfaffirmation and impedes acknowledgment of the importance of physiotherapy among other health care professionals and the creation of a culture of safety. It is a vicious circle that needs to be broken if the concept of patient safety is to be integrated into routine physiotherapy practice. Physiotherapy associations and experts in patient safety from other disciplines must strive to foster a culture of patient safety in physiotherapy and lay the bases for the creation of effective systems for reporting incidents, AEs, and near misses. Concerted efforts in this regard should also help reduce the wide variability observed to date [65]. Due to the paucity of evidence on patient safety and physiotherapy and the not well spread consciousness of the situation among the professionals, it is difficult to state which populations receiving physiotherapy are more at risk for medical errors and adverse events in this field.
