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Journal Article > Study
An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.
Hagley GW, Mills PD, Shiner B, Hemphill RR. Phys Ther. 2018;98:223-230.
This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.
Cases & Commentaries
- Web M&M
Jeffrey Driver, JD, MBA ; October 2004
Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented.