Adverse Events in Physiotherapy - a Register That Protects You and the Patient

Tomasz is running a shortwave diathermy treatment on a patient recovering from a shoulder injury. Everything goes routinely, until the patient reports redness and a burning sensation on the skin where the electrode sat. Nothing serious -- it fades within a few hours -- but Tomasz wonders whether he should write this down anywhere, or whether it's better not to make a fuss about it, so it doesn't look like he made a mistake. Most physiotherapists ask themselves exactly this question in such a situation, and it's precisely that reflex -- "better not to record it" -- that poses the biggest risk to a practice.

An adverse event is not an admission of guilt. It's a clinical fact that needs to be recorded, analyzed, and used to prevent recurrence. Poland's Act on Quality in Healthcare and Patient Safety of 16 June 2023 explicitly introduces a "no-blame" culture into the Polish healthcare system -- the purpose of recording adverse events is systemic analysis, not finding someone to blame. In this article we explain what counts as an adverse event in physiotherapy, how to keep a register that protects the practice instead of burdening it, and how to link it to the quality management system and to professional liability insurance.

What is an adverse event in physiotherapy

An adverse event is any unplanned occurrence, unfavorable to the patient, connected with the provision of healthcare, that doesn't result from the natural course of an illness or injury but arises in connection with the treatment or therapy process itself. In a physiotherapy practice, this doesn't have to be anything dramatic -- most adverse events are borderline situations that are easy to either downplay or, conversely, hide out of fear of consequences.

Typical examples in physiotherapy practice

• Fainting or feeling faint during a treatment -- e.g. a vasovagal reaction to a first session of dry needling, or during intensive mobilization.
• Burns from physiotherapy modalities -- overly intensive shortwave diathermy, a misconfigured lamp, or excessive continuous-mode ultrasound exposure.
• Worsening of the patient's condition after manual therapy or manipulation -- increased pain, reduced range of motion, or neurological symptoms appearing after the treatment that weren't present before.
• A patient fall from the treatment table -- e.g. while moving from a lying to a sitting position in a patient experiencing dizziness.
• A fall on the way to the practice -- on a slippery waiting-room floor, at the threshold, or on the stairs leading up to the practice.

The common denominator in all these situations: the patient experienced something unfavorable in connection with their visit to the practice, regardless of whether it was caused by the therapist's actions, the state of the facility, or an individual reaction of the patient's body. We cover related risks and obligations in more detail in the article on physiotherapist professional liability insurance.

An adverse event is not an admission of a mistake

This is the single most important distinction in the whole topic, and also the most common reason practices don't keep any register at all. There's a widespread belief that recording an adverse event is, in practice, tantamount to admitting the therapist made a mistake -- a straight path to a claim or reputational damage.

In fact, the Act on Quality in Healthcare introduces exactly the opposite logic, known as the "no-blame" culture. It assumes that:

• Adverse events in healthcare overwhelmingly result from imperfections in systems and procedures, not from individual bad intent or gross staff negligence.
• The purpose of reporting and recording such events is to identify weak points in the process -- e.g. a missing procedure for checking device parameters before a treatment, or the absence of an anti-slip mat by the treatment table -- not to determine who's at fault.
• Staff who report an adverse event should not face disciplinary consequences for doing so, provided they acted in accordance with applicable procedures and in good faith.
• Recording events is preventive in nature -- the more a practice knows about what went wrong, the more effectively it can prevent it from happening again.

In practice, this means that a practice that keeps a diligent adverse event register is building evidence of due diligence -- it documents that it responds to warning signs, analyzes causes, and implements improvements. That's the exact opposite of the situation where staying silent about an event would somehow protect the practice. The register is part of a broader quality management system, which we cover in the article on the internal quality management system (WSZJiB) at a healthcare provider.

[SP] Example -- Solo practice: After the diathermy episode described at the start, Tomasz records the event in a simple register kept as a spreadsheet: date, description (skin redness after a diathermy treatment), circumstances (standard parameters, first treatment for this patient), actions taken (treatment stopped, area cooled, patient observed), conclusions (shorten exposure time for the first treatment in fair-skinned patients). He doesn't write "I made a mistake" anywhere -- he describes the facts and the resulting change to the procedure.

How to document an event so the entry helps rather than harms

This is the practical crux of the topic: how you phrase an entry matters enormously if a patient ever files a claim or you need to report a loss to your professional liability insurer. A well-kept register is evidence that the practice acted professionally. A badly phrased entry can be read as an admission of guilt, even if that was never the intent.

Rules for writing an entry

• Stick to facts, not judgments. Instead of "I set the device parameters wrong," write "standard treatment parameters were applied in accordance with the protocol; the patient experienced a skin reaction." A fact is neutral, a judgment is subjective and can be used against the therapist.
• Record the exact time and circumstances. Date, time, type of treatment, device settings, stage of therapy, presence of other people in the room.
• Describe the patient's reaction in their own words where possible. A direct quote from the patient ("reported a burning sensation near the electrode") is more credible than the therapist's interpretation.
• Record the immediate actions taken. What was done in response to the event -- stopping the treatment, providing first aid, observation, referral to a doctor.
• Avoid language that admits fault -- "due to my oversight," "I should have checked" -- even if that's how it feels at the moment. Root-cause analysis has its own separate place in the register, described below, and it too should take a systemic rather than a personal form.
• Don't hide or skip an event. No entry for an event that actually happened is worse than a factual, neutral entry -- during an inspection or a legal dispute, a gap in the documentation raises far more suspicion than a documented, analyzed event.

Register column	What to record
Date and time	The exact moment the event occurred
Description of the event	Facts -- what happened, without judgment or interpretation
Circumstances	Type of treatment, parameters, stage of therapy, people present
Actions taken	Immediate response -- what was done at the time
Conclusions / corrective actions	Change to the procedure, training, equipment modification

Root-cause analysis and corrective action -- a simple framework

Recording the facts is only half the process. The "no-blame" culture requires that, after logging an event, the practice run a short root-cause analysis and turn the conclusions into a concrete change in procedure. This doesn't require an elaborate methodology -- a simple three-step framework is enough for a physiotherapy practice.

1. What happened -- a factual description of the event, following the rules above.
2. Why it happened -- a systemic, not personal, analysis. Was a procedure missing? Did equipment need servicing? Was the patient sufficiently informed about possible reactions? Did the facility itself (e.g. a slippery floor, missing handrail) play a role?
3. What we're changing -- a concrete corrective action: adding an item to the pre-treatment checklist, shortening exposure time for a specific patient group, buying an anti-slip mat, updating the consent form with additional information about possible reactions.

[GR] Example -- Group practice: At a practice employing four physiotherapists, two cases of dizziness were recorded within two months when patients stood up from the table after cervical manual therapy. The practice manager reviews both register entries, spots a common pattern (no time allowed for positional adaptation), and introduces a mandatory procedure: after cervical mobilization treatments, the patient stays seated on the table for at least 60 seconds before standing, with the therapist assisting during the transition. The change is recorded as a corrective action against both events.

A register kept this way shows something no single note in a patient's chart ever could -- continuity and a systematic approach to safety in the practice.

The register as part of the quality system and OC protection

The adverse event register doesn't exist in isolation from the rest of the practice's documentation. It has two natural links worth keeping in mind when implementing it.

Link to the internal quality management system

The Act on Quality in Healthcare requires healthcare providers to implement an internal quality and safety management system (WSZJiB), one component of which is precisely the process of reporting and analyzing adverse events. The register discussed in this article is, in practice, the operational tool of that system -- it's the register that supplies the data a practice can use to show that its quality system actually works, rather than existing only on paper. We cover the full scope of implementing a WSZJiB at a physiotherapy practice in a separate article.

Link to professional liability (OC) insurance

The second link is equally important from a practical standpoint. When reporting a loss to an OC insurer -- whether initiated by the patient or by the practice itself out of caution -- a diligently kept adverse event register is one of the strongest pieces of evidence of due diligence. It shows that the practice not only responded to a specific event but has a documented, repeatable process for handling such situations. Insurers and their claims assessors pay close attention to whether an event was recorded close in time to when it occurred, whether the description is consistent with other documentation (e.g. the patient's chart), and whether follow-up action was taken.

Frequently asked questions

Does every adverse event have to be reported to the patient?

Recording an event in the practice's internal register is a separate matter from informing the patient about their health status and the course of therapy, which follows from the general duty to inform patients. In practice, it's worth discussing what happened with the patient in a factual manner appropriate to the situation -- this builds trust and reduces the risk of the dispute escalating, regardless of the internal record of the event.

Is keeping an adverse event register mandatory for a solo physiotherapy practice?

The Act on Quality in Healthcare and Patient Safety directs obligations related to the internal quality management system primarily at entities carrying out healthcare activities. Regardless of the exact scope of the formal obligation in a given case, keeping such a register is good practice for every practice, including solo ones -- it's the simplest way to build evidence of due diligence and systematically improve patient safety.

What should you do if the adverse event register needs to describe an event involving another therapist on the team?

The same rules apply as for your own event -- the description should be factual, neutral, and focused on circumstances and systemic analysis, not on judging a specific person's work. The "no-blame" culture applies to the whole team: the goal is to jointly develop a corrective action, not to identify someone to blame. It's worth having the therapist involved in the event take part in the root-cause analysis themselves.

How long should a physiotherapy practice keep its adverse event register?

It's worth treating the adverse event register the same way as the rest of the practice's medical documentation and quality-system documentation -- that is, keeping it long-term, ideally for the entire period required for a given patient's medical records, and for events connected with a potential claim, at least until the statute of limitations for civil claims has expired.

CTA: An adverse event register is one component of a complete documentation and safety system for your practice. FizjoReady packages include procedures, templates, and checklists that help you organize your documentation in line with current requirements. See FizjoReady packages →

Related articles:
- WSZJiB -- internal quality management system at a healthcare provider
- Physiotherapy service complaints
- Physiotherapist professional liability insurance