Lesson 3: Drug Classes & Therapy Implications

Medical errors can arise from a complex interplay of human, organizational, environmental, and patient-related factors. Addressing these contributors requires a systems-based approach that emphasizes education, communication, and process redesign. By understanding these factors, healthcare organizations can implement targeted interventions to enhance patient safety and reduce preventable harm.

Human Factors

Human factors are among the most significant contributors to medical errors in therapy practice. These include cognitive biases and clinical reasoning errors, fatigue and workload, and insufficient knowledge and experience. Biases such as confirmation bias and anchoring distort clinical judgment (Orthopaedic Section of APTA, 2024). High patient volumes and extended working hours increase fatigue, impairing attention and decision-making (Jalali, 2025). Lack of familiarity with specific conditions or therapeutic techniques can lead to misjudgment and inappropriate interventions (Mu et al., 2006).

Organizational and System-Level Factors

Systemic issues create latent conditions that predispose therapists to errors: understaffing and time pressure, poor communication and coordination, and inadequate training and continuing education. Inadequate staffing levels force therapists to manage more patients than recommended, increasing the likelihood of rushed assessments (Naseralallah et al., 2023). Ineffective communication among interdisciplinary teams often results in conflicting treatment plans or overlooked contraindications (Lohman et al., 2008). Limited access to ongoing professional development contributes to outdated practices (Gonzalez-Caminal et al., 2022).

Environmental and Technological Factors

Environmental distractions and equipment-related issues also play a role: distracting work environments increase cognitive load, reducing accuracy in documentation and intervention delivery (Jalali, 2025). Malfunctioning rehabilitation devices or poorly designed electronic health record systems can lead to errors in therapy execution or documentation (Uberoi et al., 2007).

Patient-Related Factors

Patients themselves can contribute indirectly to medical errors in therapy practice due to characteristics that complicate care delivery. These factors often interact with systemic and human elements, increasing the likelihood of mistakes.

Complexity of Medical Conditions: Patients with multiple comorbidities—such as cardiovascular disease, diabetes, and neurological impairments—require highly individualized care plans. The complexity of these conditions can lead to conflicting treatment priorities, making it easier for therapists to overlook contraindications or fail to adjust interventions appropriately (Atchison & Dirette, 2023).

Limited Health Literacy: Low health literacy affects a patient’s ability to understand therapy instructions, medication precautions, and safety guidelines. Misinterpretation of home exercise programs or failure to follow weight-bearing restrictions can lead to injury or delayed recovery (WHO, 2023).

Cultural and Language Barriers: Language differences and cultural beliefs about health and rehabilitation can hinder effective communication. Misunderstandings about therapy goals or reluctance to engage in certain interventions may result in incomplete or unsafe care (Gonzalez-Caminal et al., 2022).

Cognitive and Psychological Factors: Patients with cognitive impairments, such as dementia or traumatic brain injury, may struggle to follow instructions accurately. Similarly, anxiety or depression can reduce engagement and adherence, complicating therapy delivery and increasing the risk of errors during unsupervised activities (Mu et al., 2006).

Socioeconomic Constraints: Financial limitations, lack of transportation, and inadequate access to assistive devices can lead patients to modify or skip prescribed interventions, creating safety risks (Jalali, 2025).

Case Scenario:
A documentation error caused a patient to receive two therapy sessions in one day instead of one, leading to fatigue and delayed recovery. Investigation revealed:

• Human Factors: Therapist fatigue
• Organizational Issues: High caseload and time pressure
• Technological Limitations: Lack of automated alerts in the EHR system

Solutions:

• Workload redistribution
• Staff training on documentation accuracy
• Integration of automated scheduling alerts into the EHR platform