Four Stages and Safety

One of the themes of this blog is the overlap between safety and organization, and one of the many things I like about Dalton, Thompson and Price's model is how it makes it possible to get more concrete and explicit about that overlap.

In an earlier post I wrote: During COVID was when it began to dawn on me that POCA Tech needed to do something extremely different than anything I’d ever seen in relationship to acupuncture safety. The question “how are you going to keep us safe?” isn’t the question we want to train our students to ask of anyone. What we want is for our students to ask themselves, “how can I participate in creating more safety for everyone, myself included?” because once they graduate and are responsible for a clinic, creating safety for everyone will be their job. If they’re expecting someone else to do it for them at that point they’ll have a big problem, and if we allowed them to get all the way through school with that expectation, then it’s pretty much our fault.

“How are you going to keep us safe?” is a question people ask when they’re in Stage 1 of Dalton, Thompson and Price's model. “How can I keep myself safe?” is what someone in Stage 2 might ask. It’s not until you get to Stage 3 that you can take on the perspective of local leadership and think “how can I create more safety for everyone, myself included?”

I hope that this blog has demonstrated that creating acupuncture safety in the real world is a complex and nuanced undertaking, requiring communication, coordination, and managing uncertainty. (All tasks of leadership!) It would be great if creating acupuncture safety were just a matter of following checklists, but it’s not; acupuncture’s too weird. People in Stage 1 and Stage 2 of Dalton, Thompson and Price's model can follow checklists. To create a culture of safety for acupuncture, we need people who are able and willing to do Stage 3 work.

I think this is even more true in community acupuncture than conventional acupuncture. To dig into that further, let’s talk about two acupuncture safety incidents that weren’t reported to the AERD -- I came across them in my, uh, travels. (When you’re an acu safety nerd, you hear things!)

The first incident involves one of the highest payouts ever from a malpractice insurance company for an acupuncture claim, somewhere north of a million dollars. I bet you’re thinking, oh no, not another pneumothorax story! Nope. This incident, which landed the patient in the hospital for many weeks and required multiple surgeries, happened when a patient sat up after an acupuncture treatment, got dizzy, and fell off the treatment table face first onto the floor. The patient fractured a vertebra, lost teeth, and sustained other injuries which, their lawyers argued, were a result of the acupuncturist’s failure to manage a known adverse reaction to acupuncture treatment: dizziness. The clinic setting was one in which the acupuncturist was treating multiple patients in individual rooms and so was not present when the patient tried to get up.

Dizziness represents 10.39% of reports in our AERD.

The second incident, which fortunately involved no injuries and no malpractice claims, happened in a community clinic awhile ago. While the acupuncturist was treating other people in the room, a patient who was notably small and frail had some trouble getting the footrest of her recliner into place. She leaned over to try to adjust it and pitched herself out of the chair, landing on the floor. The acupuncturist rushed over to help her and while the patient was shaken up, she wasn’t hurt or angry.

In both these incidents, I don’t think the acupuncturists did anything wrong. These are accidents, and arguably really good evidence for why we need liability insurance in our practices. I think they’re important, though, as examples of how managing safety issues requires not just looking at what the acupuncturist does in their role as a healthcare professional (that’s the kind of Stage 2 stuff that the acupuncture profession tends to focus on) but how patients interact with the clinic space and with acupuncture itself.

Dizziness after acupuncture is not an example of a practitioner error. It’s an adverse event that can happen regardless of whether anyone did anything wrong. Legally, we’re responsible for managing adverse events in our practices, not just avoiding mistakes. Lots of acupuncturists are confused about that. Acupuncturists insisting that safety incidents only happen as a result of bad practitioners doing bad things (see also, “undertrained physical therapists”) does everybody a disservice. It’s irresponsible -- literally.

Community acupuncture minimizes the role of the white-coated authority figure and emphasizes the importance of how patients interact with the clinic space and with acupuncture itself. The point of community acupuncture is to create a resource and then empower patients to use it on their own terms. That puts community acupuncturists in a good position to look at safety from a more holistic perspective and to see the places where safety issues can arise that have more to do with patients’ relationship with acupuncture and with the clinic space (including the furniture!) and not so much with us, the providers. It offers us the opportunity to be neutral, curious, and nerdy -- to take safety less personally while still taking it very seriously.

In the second incident, where the patient fell out of a recliner and on to the floor, the acupuncturist commented later that they thought the patient didn’t blame them for the accident because they had a positive, supportive, transparent relationship before anything negative happened. The patient knew that the acupuncturist had their best interests at heart and that knowledge was reinforced by the way the acupuncturist managed the incident. They didn’t get defensive and they showed their concern for the patient’s safety. They strategized together how they could avoid anything like that happening again.

We can’t control whether accidents happen, that’s why they’re accidents! What we can control is whether our practices reflect a culture of safety. And a culture of safety doesn’t just happen if we follow all the rules. A culture of safety is a creative project and it has to be built out of communication, coordination, and planning. In Stage 3, a person “clarifies complex data or situations so that others can comprehend, respond and contribute”. Acupuncture safety is a complex situation and everyone who interacts with acupuncture -- practitioners, patients, students, regulators -- need support in comprehending, responding, and contributing so that we can build a culture of safety together.