"The Patient Was Faster than I Could Think" Errors in Acute Care Physiotherapy: A Mixed-methods Survey

Patient safety aims to prevent avoidable harm in health care, yet adverse events affect 10% of hospitalized patients. Data on physiotherapy-related errors and consequences remain scarce. This study explored the nature of self-reported errors among physiotherapists working in acute care hospitals in Switzerland.

A cross-sectional, mixed-methods study was conducted using an anonymous, web-based survey. Physiotherapists were invited to report errors they had committed in acute care settings. They were asked to describe the context and to categorize the resulting harm. Afterward, they could select any previously-committed errors from a predefined list. Responses were analyzed using content analysis, descriptive statistics, and triangulation.

Sixty-two physiotherapists reported 79 errors across various specialties, experiences, and hospital sizes. The majority of errors occurred in musculoskeletal and medical settings. While most errors caused no patient harm, 21 (27%) resulted in temporary to permanent harm. Researchers assessed the level of harm as higher than that of participants in 26 (33%) cases. Most errors had multiple contributing factors [73 (92%)]. Interprofessional miscommunication and blame were common. Data triangulation revealed gaps in physiotherapists' awareness and conceptualization of errors.

Physiotherapy-related errors were common and were influenced by a mix of system-level and human factors. Most self-reported errors did not result in serious harm, yet physiotherapists' understanding of errors was concerning. A proactive, interprofessional, and open safety culture seems crucial to improve both patient safety and clinical practice in acute care physiotherapy.