Neuro OT and Patient Safety

As today marks the first ever World Patient Safety Day (17 September 2019), we ask, “How do we assess risk to safeguard a brain injured person?” and “When is it worth taking a risk?” 

How do we assess risk within Neuro OT?

Safeguarding brain injury survivors lies at the foundation of Krysalis’s neuro OT thinking, not least because of a survivor’s vulnerabilities following an acquired brain injury and the complexities associated with planning a hospital discharge.

Family members, also, may be suffering from trauma triggered by the injury event. They too have been jettisoned in an unknown sea where the word ‘risk’ has likely taken on a whole new meaning. 

The process of carrying out an evidence-based risk assessment, is a task that many individuals, families or carers will have little understanding of in terms of the importance of the documentation and the complexities of risk associated with everyday tasks.  

Brain injury presents an individual with many complex challenges. Tasks that were once undertaken with little or no planning become ‘risks’ that are managed to safeguard an individual. The rehabilitation process, however, by its nature is designed to challenge an individual and therefore to a lesser or greater degree introduce elements of risk. The key is to ensure that the processes that are put in place manage those risks to optimise function and promote independence.  

Neuro OTs are trained to assess, track, locate, reduce or eliminate risks over the time they spend with their clients. They have the tools to help them do this; tools developed to meet the standards set by the Royal College of Occupational Therapists (RCOT).

These assessment tools can be used to assess risk in a variety of circumstances, including:

• occupation
• occupation-based practice
• physical abilities and goals
• participation 
• environment
• specialist areas, such as body function. 

All these fields impact on our activities of daily living (ADLs); the daily self-care activities those of us with fully functioning brains learn to take for granted.

And within all these fields, there are risks. It is not difficult, for example, to imagine how the width of a doorway could make access to a wheelchair difficult, and injury, as a result, more likely. But how, in the case of a client whose cognitive impairments are still being assessed, will a trip to the local supermarket be dealt with? What could pose a risk during showering, transferring from one site to another, cooking a meal, or forging a new life by trying new activities?

The complexities of the social environment, or more specifically an individual's local community, for example, may present with a wide number of risks and hazards for an individual with cognitive and sensory needs.

 An Occupational Therapist will be able to advise on risks that can be managed in advance by avoiding certain environments or putting in place guidance / strategies to assist with managing behaviour; these can be compared to risks that are measured and should be approached in line with an agreed rehabilitation plan.

The RCOT’s approved risk assessment tools provide internationally accepted scoring systems that enable Neuro OTs to measure and evaluate risk in any situation.

The results, when viewed along with the Neuro OT’s clinical observations, inform recommendations that will reduce risks, or avoid them altogether.

But in brain injury rehabilitation, how do we decide if a risk is worth taking?

Last year, the RCOT published a guide entitled ‘Embracing risk; enabling choice’ in which it clarified risk assessment processes and called on rehabilitation practitioners to consider their clinical perspective on risk.

   It is your role, as far as possible, to enable people to overcome the barriers that prevent them from doing the activities that matter to them; to take opportunities and not to see risk as another barrier.   

RCOT guidance, 2018. (1)

Krysalis’s Clinical Director, Jo Throp advises that in clinical practice the risk assessment process should be grounded in the clinical experience of the Occupational Therapist, combined with a detailed understanding of the individual's needs, including their functional abilities and limitations. Consideration should also be given to:

• The potential for the physical and social environment to change resulting in fluctuating risk.
• The skills of the people supporting the individual with brain injury as poorly trained or unfamiliar staff will result in increased risks.
• The views of the individual and their family, and an understanding of their belief systems.
• Whether there is a recognition that the risks identified are important enough to act on advice and to ‘buy into’ advice. In the context of brain injury, some individuals may lack insights into their difficulties which will require further assessment. 
• An individual’s goals; these motivators are important as, arguably, an individual who is encouraged to undertake a goal that they show little interest in could result in an increased level of risk due to disengagement or lack of concentration.

In ensuring that a comprehensive occupational therapy assessment and analysis is undertaken, it is more likely that a measured risk is taken.   

Risk assessment: a developing field of science.

According to a recent review of advances in risk assessment processes (2), the first scientific reports on methods of appropriately assessing and managing risk began to emerge just 30 to 40 years ago. 

Since then, more sophisticated techniques have been developed and risk analytical approaches are now widespread, including those used by Neuro Occupational Therapists.

But conversations continue around the need for “a strong, unifying scientific platform” for assessing risk, to decide on ‘greyer’ areas that are less easy to define, including:

• Terminology and concepts, such as ‘risk’ or ‘vulnerability’.
• How ‘uncertainty’ or levels of probability are measured.
• How much importance is placed on knowledge during the assessments.
• The requirements for management and review.

The Norwegian university report concluded: “The risk field needs more researchers that have the passion and enthusiasm to bring this field to the next level.”

World Patient Safety Day

In May this year, The World Health Organisation announced September 17 as World Patient Safety Day in an ongoing bid to:

• Increase global action on patient safety.
• Install measures to reduce avoidable patient harm.
• Share patient safety awareness in care settings.
• Raise public and media awareness of patient safety concerns.
• Trial new patient safety ideas.
• Help patients assist with their own safety.

The September 17 addition to WHO’s official health dates came in response to claims by patient advocates that patient harm has now become “a global public health problem”.

According to the International Alliance of Patient Organizations (IAPO): “Every second of every day, someone in the world suffers avoidable harm due to receiving unsafe care or have the risk of being harmed while receiving health care.” (3) 

World Patient Safety Day is, IAPO concludes, “recognition of the scale of avoidable harm linked with medical errors.”

References

1. Royal College of Occupational Therapists, Embracing risk, enabling choice - Guidance for occupational therapists. 2018.
2. Aven, Terje. Risk Assessment and risk management: Review of recent advances on their foundation. s.l. : European Journal of Operational Research, 2015.
3. Organisations, International Alliance of Patients'. World Patient Safety Day adopted by 72nd World Health Assembly. s.l. May 2019.