**4. Critical concepts: the link between malpractice and patient safety**

Data are essential for guiding the implementation of patient safety systems but are very scarce in the field of physiotherapy [17]. Information on errors and AEs in the health sciences comes from critical incident reports, complaints, malpractice or fraudulence claims, preventable death reports, and audits. While these reports contain indirect indicators of safety failures, [9, 17] they show just the tip of the iceberg. In addition, they focus on outcomes rather than processes.

A clear understanding of what constitutes an error and an AE is necessary for effective reporting and recording, and in the framework of patient safety, it is particularly important to distinguish between malpractice and error. The literature contains reports of malpractice in physiotherapy [34]. Malpractice is wrongful conduct by a health care professional that causes injury to a patient. It always involves negligence and legal responsibility [35]. Most AEs, however, are unintended and caused by human error or latent system errors missed by humans [36–38].

According to Reason's theory of human error, safety is a complex and multilayered system [39]. The basic premise is that humans are fallible and as a result, errors will occur, despite attempts to prevent them. This is why it is imperative to implement effective detection, prevention, and mitigation systems [40].

The predominant focus on assigning individual blame for AEs impeded advances in patient safety for many years, as the tendency was to cover up errors out of fear of personal consequences. In the present culture of patient safety, it is recognized that errors will occur because humans are fallible; biological systems are inherently complex (systemic alterations, for example, can occur during respiratory physiotherapy of patients with neurological disorders), and organizational and working systems have functional weak points (latent errors). The goal of patient safety is to identify weaknesses in each of the above dimensions and evaluate and decide which measures should be implemented to safeguard against what are mostly preventable errors [9, 17, 40]. As WHO has stated in several of its documents, most AEs are preventable [1, 5, 8].

In professions, such as physiotherapy, where patient safety is still in its infancy and error perception and recognition are lacking, error analyses tend to focus on individual blame rather than on the components of the process leading up to the error. These analyses thus tend to be based on a deficient understanding of the care process and an

#### **Figure 2.**

*Scales comparing the legal and quality systems.*

excessive focus on "intentionality" (active errors). The focal point is, therefore, one malpractice, which is a criminal act that is directly or indirectly punishable [41].

Without a climate of trust in which errors are viewed as an opportunity for learning and improvement rather than a cause for blame, it is difficult to create a safety culture [9, 40]. Patient safety is not about malpractice, it is about human factors and systems, which both have their limitations. It is about detecting problems that could have been prevented and implementing the necessary steps to ensure that they do not recur [38, 42]. It is about being proactive rather than defensive, which is the typical approach in malpractice cases [43].

As stated by Di Luca et al. [36] "The healthcare disciplines of patient safety and risk management are deeply interrelated and interdependent. Patient safety alone is blind to consequences beyond outcome, and risk management alone can manage and mitigate but not prevent errors" [36]. Actions were taken to reduce the risk of malpractice, and its legislative consequences have not resulted in improved patient safety indicators [35, 38]. It is thus important to understand the differences between the two concepts. It would, however, also be interesting to analyze their interconnections, as they probably have overlapping or complementary features (**Figure 2**) [36, 37]. When faced with a malpractice claim, it is essential to conduct a root-cause analysis of what occurred from the perspective of patient safety to gain an overall picture that captures the complementary aspects of both the legal and the quality system.

Investigations into patient safety and AEs serve to minimize risks and errors in care processes and/or related administrative processes. Scheirton et al. [44] identified six types of errors and AEs in the field of occupational and physical therapy practice:


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


Other authors in the field have analyzed AEs, risk factors, and effects associated with different types of physiotherapy techniques, modalities, and situations, such as dry needling [45], manual therapy [46–51], hospital falls, and early mobilization in orthopedic [30, 32, 52] and/or intensive care patients [31].

Data collection is also useful for determining procedures and techniques, in addition to being beneficial, which are effective and safe to implement, such as mobilization and rehabilitation in intensive care units [53], active mobilization in patients requiring continuous renal replacement therapy [54], cancer rehabilitation [55], lower limb plyometric training in older adults [56], and cervical traction and exercise in patients with neck pain (clinical prediction rule to identify, which patients are most likely to benefit) [57].

Most studies of AEs in physiotherapy have focused on the intervention stage of the care process, but many techniques used for treatment are also used for diagnostic purposes (e.g., neurodynamic tests) [58, 59]. Accordingly, data collected on interventions could be extrapolated to other stages of the care pathway (e.g., evaluation). Errors that occur in later stages of the process are linked to errors or decisions made earlier on. A poor evaluation thus can lead to misdiagnosis (**Table 2**). If efficient reporting and recording systems are to be created, physiotherapists must be involved in the development of quality systems [17, 60] and have a clear understanding of the data generated.


#### **Table 2.**

*Errors that can occur during the different stages of physiotherapy care process.*
