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2021, Number 4

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Rev Cubana Invest Bioméd 2021; 40 (4)

Adverse event and patient safety in physiotherapy

Milena HP, Tatiana OL, Andrés GJ

Language: Spanish
References: 59
Page: 1-18
PDF size: 232.10 Kb.


ABSTRACT

Introduction: The occurrence of adverse events in health care has prompted the development of many prevention strategies. In the field of rehabilitation, particularly in physiotherapy, their report, analysis and effects have been described in a large number of articles.
Objective: Determine the effects of the adverse events occurring in physiotherapy sessions, their order of appearance, causes and health determinants contributed to develop better prevention and patient safety strategies.
Methods: A systematic search for scientific articles was conducted in six databases: PubMed, Scopus, ProQuest, Pedro, ScienceDirect and Google Scholar, using the key terms “adverse effect”, “risk management” and “physiotherapy”. A total 1 145 articles were retrieved, from which 44 were selected for the study.
Conclusions: More active participation should be achieved in physiotherapy-specific and multidisciplinary strategies fostering the safety of patients attending rehabilitation services, as well as in the continuing conduct of studies exploring other areas of physiotherapy and the incidence of adverse events therein.


REFERENCES

  1. Ferreira A, Chiminelli V. Aspectos significativos surgidos de la experiencia de haber sido responsable de un evento adverso en salud. Aqui. 2014;14(3):294-302. Disponible en: http://dx.doi.org/10.5294/aqui.2014.14.3.2

  2. Luengas S. Seguridad del paciente un modelo organizacional para el control sistemático de los riesgos en atención en salud. Centro de Gestión Hospitalaria, Fundación Corona. 2009.

  3. Fernandez N. Los eventos adversos y la calidad de atención: Estrategias para mejorar la seguridad de los pacientes pediátricos. Archivos Argentinos de Pediatría. 2004;102(5):402-410

  4. Palacios A, Bareño J. Factores asociados a eventos adversos en pacientes hospitalizados en una entidad de salud en Colombia. Revista CES Med. 2012;26(1):19-28. Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120-87052012000100003&lng=en

  5. Araújo W, Baccaro H, Araújo A, Jonas J, Salomao H, Siqueira J. et al. Impact of a continuous education program on the quality of assistance offered by intensive care physiotherapy. Rev Bras Ter Intensiva. 2014;26(1):7-12. Disponible en: http://dx.doi.org/10.5935/0103-507X.20140002

  6. Donoso A, Fuentes I. Eventos adversos en UCI. Rev Chil Pediatr. 2004;75(3):233-239. Disponible en: http://dx.doi.org/10.4067/S0370-41062004000300004

  7. Gaitán H, Eslava J, Rodríguez N, Forero V, Santofimio D, Altahona H. Incidencia y evitabilidad de eventos adversos en pacientes hospitalizados en tres instituciones hospitalarias en Colombia, 2006. Rev. salud pública. 2008;10(2):215-226. Disponible en http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0124-00642008000200002&lng=en

  8. Cardoso P, Cabral L, de Carvalho R, Ribeiro S. Incidence and primary causes of unplanned extubation in a neonatal intensive care unit. Rev Bras Ter Intensiva. 2012;24(3):230-235. Disponible en: https://doi.org/10.1590/S0103-507X2012000300005.

  9. Ribeiro de Oliveira P, Alves Cabral L, de Carvalho Schettino R, Nascimento Santos Ribeiro S. Incidence and primary causes of unplanned extubation in a neonatal intensive care unit. Rev. bras. ter. intensive; 24(3):230-235. DOI: https://doi.org/10.1590/S0103-507X2012000300005

  10. Sharek P, Hotbar JD Mason W, et al. Adverse events in the neonatal intensive care unit: development, testing and findings of an NICU-focused trigger toll to identifity harm in North Amercian NICUs. Pediatrics. 2006;(118):1332-1340. Disponible en: https://doi.org/10.1542/peds.2006-0565

  11. Barrionuevo L, Esandi M. Epidemiología de eventos adversos en el servicio de neonatología de un hospital público regional en la Argentina. Arch Argent Pediatr. 2010;108(4):303-310. DOI: 10.1590/s0325-00752010000400003.

  12. Lee HC, Huang CL, Ho SH, Sung WH. The effect of a virtual reality game intervention on balance for patients with stroke: a randomized controlled trial. Games for Health Journal. 2017;6(5):303-311.

  13. Paanalahti K, Holm L, Nordin M, Asker M, Lyander J, Skillgae E. Adverse events after manual therapy among patients seeking care for neck and/or back pain: a randomized controlled trial. BMC Musculoskeletal Disorders. 2014;15(77):1-10. Disponible en: https://doi.org/10.1186/1471-2474-15-77

  14. Shields N, Bennell K, Radcliffe J, Taylor N. Is strength training feasible for young people with Prader-Willi syndrome? A phase I randomised controlled trial. Physiotherapy. 2019;(106);136-144. Disponible en: https://doi.org/10.1016/j.physio.2019.01.016

  15. Ribeiro J, Vieira G, Beline T, Pereira L, Guedes K, Costa G, et al. Effects of kinect adventures games versus conventional physical therapy on postural control in elderly people: a randomized controlled trial. Games for Health Journal. 2018;7(1):1-13. Disponible en: https://doi.org/10.1089/g4h.2017.0065

  16. Delgado J, Toro R, Rascovsky S, Arango A, Angel GJ, Calvo V, et al. Chloral hydrate in pediatric magnetic resonance imaging: Evaluation of a 10-year sedation experience administered by radiologists. Pediatr Radiol. 2015;45(108):14-23. Disponible en: https://doi.org/10.1007/s00247-014-3091-0

  17. Hernández I, Saenz M. Características de los efectos adversos detectados en una unidad de cuidados intensivos de adultos. Revista calidad asistencial. 2008;23(4):150-157. Disponible en: https://doi.org/10.1016/S1134-282X(08)72127-4

  18. Lorenzo R, Sánchez M, Santana L, Cobian L, García C. Gestión de la calidad en una unidad de cuidados intensivos: implementación de la norma ISO 9001:2008. Med Intesiva. 2010;34(7):476-482. DOI:10.1016/j.medin.2009.06.007.

  19. Hidalgo C, Tricas J, Nicolás G, Gimenez C, Gomez A, San Gumersindo S. Manipulación cervical: aproximación anatómico-biomecánica frente a los posibles riesgos e implicaciones prácticas. Fisioterapia. 2007;29(6):298-303. Disponible en: https://doi.org/10.1016/S0211-5638(07)74455-3.

  20. Leditschke A, Green M, Irvine J, Mitchell I. What are the barriers to mobilizing intensive care patients? Cardiopulmonary. Cardiopulm Phys Ther J. 2012;23(1):26.29. Disponible en: https://pubmed.ncbi.nlm.nih.gov/22807652/

  21. Wegner W, Pedro E. La seguridad del paciente en las circunstancias de cuidado: prevención de eventos adversos en la hospitalización infantil. Revista Latino-Am. Enfermagem. 2012;20(3):1-8. Disponible en: https://doi.org/10.1590/S0104-11692012000300018

  22. Snyder D, Acupuncture gone awry: a case report of a patient who required surgical removal of two single-use filament needles following acupuncture treatment. J Man Manip Ther.2019;27(3):180-184. Disponible en: https://doi.org/10.1080/10669817.2019.1608010

  23. Achury D, Rodríguez S, Díaz J, Cavallo E, Zarate R, Vargas R, et al. Estudio de eventos adversos, factores y periodicidad en pacientes hospitalizados en unidades de cuidado intensivo. Enferm glob. 2016;14(42):324-340. Disponible en: https://doi.org/10.6018/eglobal.15.2.215791.

  24. Montserrat Capella, D, Suárez, M, Ortiz, L, Mira, JJ, Duarte, HG, Reveiz, L, Ambeas Group. Frequency of ambulatory care adverse events in Latin American countries: the AMBEAS/PAHO cohort study. IJQHC: JOTSFQINC. 2015;27(1), 52-59. Disponible en: https://doi.org/10.1093/intqhc/mzu100

  25. Souza G, Albergarua T, Bomfim N, Duarte A, Fraga H, Prata B. Eventos adversos do ortostatismo passivo em pacientes críticos numa unidade de terapia intensiva. ASSOBRAFIR Ciência. 2014;5(2):25-33. Disponible en: http://dx.doi.org/10.47066/2177-9333/ac.18148.

  26. Singh R, Singh A, Servoss T, Singh G. Prioritizing threats to patient safety in rural primary care. J Rural Health. 2007;(23):173-178. Disponible en: https://doi.org/10.1111/j.1748-0361.2007.00086.x

  27. Okoye O, Slater H, Rajora N. Prevalence and risk factors of intra-dialytic hypotension: A 5 year retrospective report from a single Nigerian centre. Pan Afr Med J. 2017;(28):1-12. DOI:10.11604/pamj.2017.28.62.13743

  28. Nave A, Rackoll T, Grittner U, Bläsing H, Gorsler A, Nabavi, et al. Physical Fitness Training in Patients with Subacute Stroke (PHYS-STROKE): multicentre, randomised controlled, endpoint blinded trial. BMJ. 2019;366:l5101. Disponible en https://doi.org/10.1136/bmj.l5101

  29. Magaziner J, Mangione KK, Orwig D, Baumgarten M, Magder L, Terrin M, et al. Effect of a Multicomponent Home-Based Physical Therapy Intervention on Ambulation After Hip Fracture in Older Adults: The CAP Randomized Clinical Trial. JAMA. 2019;322(10):946-956. DOI: 10.1001/jama.2019.12964

  30. Lipitz-Snyderman A, Pfister D, Classe D, Atoria C. Killen A, Epstein A. et al. Preventable and Mitigable Adverse Events in Cancer Care: Measuring Risk and Harm Across the Continuum. Cancer. 2017;123(23):4728-4736. Disponible en: https://doi.org/10.1002/cncr.30916

  31. Donchin Y, Seagull F. The hostile environment of the intensive care unit. Curr Opin Crit Care. 2002;(8):316-320. DOI: 10.1097/00075198-200208000-00008.

  32. Villareal D, Aguirre L, Gumey A, Waters D, Sinacore D, Colombo E. Aerobic or Resistance Exercise, or Both, in Dieting Obese Older Adults. N Engl J Med. 2017;376:1943-1955. DOI: 10.1056/NEJMoa1616338

  33. Griffin D, Dickenson E, Wall P, Achana F, Donovan J, Griffin J. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 2018 Jun 2;391(10136):2225-2235. DOI: https://doi.org/10.1016/S0140-6736(18)31202-9

  34. Joaquín M, Montserrat M, Rodríguez D, Santacruz J. Elementos clave en la implantación de sistemas de notificación de eventos adversos hospitalarios en América Latina. Rev Panam Salud Pública. 2013;33(1):1-12.

  35. Oyague L, Mateos R. Perfil del paciente ambulatorio en tratamiento con ansiolíticos y/o antidepresivos. Farma journal. 2019;4(2):19-29. Disponible en: https://doi.org/10.14201/fj2019421929

  36. Belli S, Cattaneo D, D'Abrosca F, Prince I, Savio G, Balbi B. A pilot study on the non-invasive management of tracheobronchial secretions in tracheostomised patients. Clin Respir J. 2019;13(10):637-642. Disponible en: https://doi.org/10.1111/crj.13074.

  37. Puentedura E, Landers M, Cleland J, Mintken P, Huijbregts P, Fernández C. Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2011;41(4):208-220. DOI: 10.2519/jospt.2011.3640

  38. Ford G, Bhakta B, Cozens A. Safety and efficacy of co-careldopa as an add-on therapy to occupational and physical therapy in patients after stroke (DARS): a randomised, double-blind, placebo-controlled trial. Lancet Neurol. 2019;18(6):530-538. DOI: 10.1111/crj.13074

  39. Oliva G, Álava F, Esquerra M, Lushchenkova O, Davins J, Vallés R. Notificación de incidentes relacionados con la seguridad del paciente en los hospitales de Cataluña durante el período de 2010-2013. Med Clin. 2014;143(Supl 1):55-61. DOI: 10.1016/j.medcli.2014.07.012

  40. Awe C, Lin S. A patient empowerment model to prevent medication errors. J Med Syst. 2003;(27):503-17. Disponible en: https://10.1023/a:1025929714386.

  41. Merino P, Martín MC, Alonso A, Gutiérrez I, Álvarez J, Becerril F. Medication errors in Spanish intensive care units. Med Intensiva. 2013;37(6):391-399. Disponible en: https://doi.org/10.1016/j.medine.2012.11.004

  42. Dessie S, Von Bargen E, Hacker M, Haviland M, Elkadry E. A randomized, double-blind, placebo-controlled trial of ona botulinumtoxin A trigger point injections for myofascial pelvic pain. Soy J Obstet Gynecol. 2014;221(5): 517.e1 - 517.e9. Disponible en: https://doi.org/10.1016/j.ajog.2019.06.044

  43. Gandhi T, Weingart S, Borus J. Adverse drugs events in ambulatory care. N Eng J Med. 2003; (348): 1556-1564. DOI: 10.1056/NEJMsa020703

  44. Woods D, Thomas E, Holl J. Ambulatory care adverse events and preventable adverse events leading to a hospital admission.Qual Saf Health Care. 2007;(16):127-131. DOI: 10.1136/qshc.2006.021147

  45. De Wet C, Bowie P. The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records. Postgrad Med J 2009;(85):176-80. DOI: 10.1136/pgmj.2008.075788.

  46. Rothschild J. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694-1700. DOI: 10.1097/01.ccm.0000171609.91035.bd.

  47. Zago M, Vaconcelos E, Quitério L, Daud-Gallotti. Carga de trabajo de enfermería e incidentes y eventos adversos en pacientes de UCI. Rev. Suj enferm. 2014;67(5):1-8. Disponible en: https://doi.org/10.1590/S0080-623420160000500020.

  48. Ministerio de Educación de Colombia. Ley 528 de 1999 de 15 de septiembre. Boletín Ofical del Estado, N° 43.711 (20/09/1999).

  49. Dowman L, Hill C, Holland A. Pulmonary rehabilitation for interstitial lung disease. Cochrane database of systematic review. 2014;6(10). Disponible en: https://doi.org/10.1002/14651858.CD006322.pub3

  50. Zeppos L, Patman S, Berney S, Adsett J, Bridson J, Paratz J. Physiotherapy intervention in intensive care is safe: an observational study. Australian journual of Physiotherapy. 2007;53(4):279-283. DOI: https://doi.org/10.1016/S0004-9514(07)70009-0

  51. Carlesso L, Cairney J, Dolovich L, Hoogenes J. Defining adverse events in manual therapy: An exploratory qualitative analysis of the patient perspective. Manual Therapy. 2011;16(5):440-446. DOI: 10.1016/j.math.2011.02.001.

  52. Fernández R, Corrochano R, Raga P. Fisioterapia en unidades de cuidado intensivo. Rev Patol Respir. 2017;20(4):130-137.

  53. Rinaldo N, Bacchi E, Coratella G, Vitali F, Milanese C, Rossi A, et al. Effects of Combined Aerobic-Strength Training vs Fitness Education Program in COPD Patients. Int J Sports Med. 2017;38(13):1001-1008. DOI: 10.1055/s-0043-112339

  54. Wang C, Schmid CH, Rones R, Kalish R , Yinh J , Goldenberg D, et al. A randomized trial of tai chi for fibromyalgia. N Engl J Med. 2010;363(8):743-754. DOI: 10.1056/NEJMoa0912611

  55. Cramer H, Sellin Ch, Schumann D, Dobos G. Yoga in Arterial Hypertension A Three-Armed, Randomized Controlled Trial. Dtsch Arztebl Int. 2018;115 (50):833-839. DOI: 10.3238/arztebl.2018.0833

  56. Villalta E, Peiris C. Early Aquatic Physical Therapy Improves Function and Does Not Increase Risk of Wound-Related Adverse Events for Adults After Orthopedic Surgery: A Systematic Review and Meta-Analysis. Archives of Physical Medicine and Rehabilitation. 2013;94(1):138-148. DOI: https://doi.org/10.1016/j.apmr.2012.07.020

  57. Evans R, Haas M, Schulz C, Leininger B, Hanson L, Bronfort G. Spinal manipulation and exercise for low back pain in adolescents: a randomized trial. Pain. 2018;159(7):1297-1307. DOI: 10.1097/j.pain.0000000000001211.

  58. Perlman A, Fogerite SG, Glass O, Bechard E, Ali A, Njike V, et al. Efficacy and Safety of Massage for Osteoarthritis of the Knee: a Randomized Clinical Trial. J Gen Intern Med. 2019;34(3):379-386. DOI: 10.1007/s11606-018-4763-5.

  59. Saha FJ, Schumann S, Cramer H, Hohmann C, Choi KE R, et al. The Effects of Cupping Massage in Patients with Chronic Neck Pain - A Randomised Controlled Trial. Complement Med Res. 2017;24(1):26-32. DOI: 10.1159/000454872.




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