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CALLS for a chiropractic adverse events reporting system to be established in Australia has received strong support, with experts saying such a system would bring chiropractors in to line with other health professionals.
In a letter published in the MJA, Mr John Cunningham, an orthopaedic spinal surgeon, and co-authors said adverse events reporting systems were crucial for maintaining quality and safety in health care. (1)
“Such systems ensure that adverse events are reviewed, thus identifying root causes of error, minimising risk of recurrence, ensuring professional accountability and improving patient care”, they wrote.
“The chiropractic profession is no more immune to error than any other. A chiropractic adverse events reporting system would bring chiropractors in line with other Australian health professionals and fulfil public entitlement to safe, high-quality care.”
Dr Laurie Tassell, president of the Chiropractors’ Association of Australia (CAA), said his association was working towards implementing an adverse events reporting system.
“CAA has recognised the fact that we don’t have an adverse events reporting system and we are examining … what’s the best way to institute one”, Dr Tassell told MJA InSight.
“It is a costly exercise and there are several models so we are in the process of doing our due diligence on which is the best system to use.”
He said the association was looking at systems used internationally and by other Australian health professionals to find the best process for the chiropractic profession and that satisfied “the public interest test”.
While Dr Tassell said the establishment of such a system was important to ensure quality control, he believed adverse events were uncommon in chiropractic.
“The three main objective measures of whether there are adverse events — registration, insurance and literature — all would indicate that there are only a small number of adverse events for the chiropractic profession”, he said.
Dr Tassell said Australia’s main insurer for chiropractors, Guild Insurance, had decreased its professional indemnity rates for chiropractors “very dramatically” over 2 successive years.
The MJA letter came in the wake of controversy surrounding a complaint to the Australian Health Practitioner Regulation Agency that chiropractic treatment had fractured a 4-month-old baby’s neck. It was later reported that the chiropractor had been cleared. (2)
Professor Debora Picone, CEO of the Australian Commission on Safety and Quality in Health Care, said adverse events reporting systems were a critical component of quality care.
“As a very bare minimum, every clinical group involved in patient care should have an adverse reporting system for events that lead to patient harm, so they should be able to record that, know what they are, go back and investigate them and give a very thorough explanation to the patients”, she said.
Professor Picone said the commission had recently released an updated version of its Australian Open Disclosure Framework, which had been endorsed by most of the major clinical societies and by state and territory health ministers. She said adoption of this framework would ensure that adverse events were appropriately detected and communicated to patients. (3)
She suggested the chiropractic profession look to Australian general practice, which was leading the world in terms of clinical professionalism with initiatives such as the Bettering the Evaluation and Care of Health program and the RACGP’s Open Disclosure policy.
Dr Philip Donato, chair of the Chiropractic Board of Australia, said section 3.11 of the board’s code of conduct endorsed open disclosure as good practice. (4)
He said the board was “very supportive” of establishing an adverse events register, even though serious adverse events from manipulation by a range of health practitioners were reported to be rare.
“In general, adverse disclosure registers have been established successfully in public health institutions (such as hospitals) and have significant value. It has been more difficult to establish them to private practice, which is how most chiropractors in Australia work”, he said.
“In any voluntary system, it is difficult to ensure there is robust reporting of adverse events related to manual therapy across the health professions.”
1. MJA 2013; 200: 204
2. The Australian 2013; Chiropractor cleared over ‘break’
3. ACSQHC 2014; Implementing the Australian Open Disclosure Framework in small practices
4. Chiropractic Board of Aust: Code of conduct
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In the mid 1980s, Federal Minister Richard Dawkins permitted Colleges to amalgamate with cash strapped universities. Chiropractors assumed roles in academia and called each other Dr. It cost them $500,000 to do this at Macquarie University. Chiropractic training is a cash cow – lots of overseas and local students study to emerge as Doctors of Chiropractic. Chiorpractic develops a dependency framework where the patient is forever returning for ‘tuneups’…rather than educating the patient to self manage their issues. Private health insurance supports this dependency cycle. Olympic snow boarder Torah Bright’s chiropractor described how he assistsed her recovery by correcting her ‘cranial mechanism’. But the main question in the above case is why manipulate a baby at all? Of course they cry at 4 months.The chiropractor was treating the baby for the chiropractic favourite; torticollis so the diagnostics were wrong in the first place. The influence of a biopsychosocial-based treatment approach to primary overt hypothyroidism: or The Effect of the Manipulation/Contemplation on Serum Cholesterol Levels in Hypercholesterolemic Subjects – wow indeed! http://www.onefoundation.org/mindbody-research/published-research/
In reply to Anonymous R.E. The title “Dr”. I totally agree with you. The NSW rego board clamped down on it and took diciplinary action. Then AHPRA came along and gave the title and it is annoying. This is a classic example of before:
http://www.idealspine.com/pages/AJCC/AJCC_new/July2000/FrontEpstein%20700.htm
and after AHPRA:
http://www.dlapiper.com/files/Publication/088e9f30-d3c9-49b6-8b67-a6e42511853d/Presentation/PublicationAttachment/43f9e194-3cf8-451c-9e0e-bd4829bbc590/Health%20Alert%20(5%20December%202011).pdf.
This issue isn’t about doctors inflating their own importance with the title Dr, it’s about lay people off the street being led to believe that chiropractors have training and knowledge they patently do not.
Can you imagine a physiotherapist titling themselves Dr without a PhD? Of course not. It’s a joke that chiropractors and podiatrists (amongst others) are allowed to fool the public by calling themselves a ‘doctor’. AHPRA should have had the wherewithall to protect the title doctor for those practitioners that patients actually think of as doctors – medically qualified doctors.
Adverse events and near-miss reporting systems are much better developed in medicine and nursing for two main reasons: 1. The are the ”default” professions, who have to receive all-comers of all severity; and 2. They are institution-based at some part of their careers (if not all). Young doctors and nurses working in hospitals develop within a culture that involves supervision, case review, M&M meetings, clinical governance, and a strong awareness of the regulatory system. The structure of this may be lost when people enter private practice, but the culture is not entirely lost, as almost all practitioners continue to collaborate and refer people to hospital. It is much more difficult to conduct clinical governernance of a large number of small businesses than in big institutions, especially if the Quality and Safety culture is not embedded.
In reply to Anonymous “What system do physios in private practice use? Surely it would be easiest for the same system to be rolled out for Chiros under the AHPRA”.
The physio’s do not have an adverse event reporting system. They have dodged quite a few bullets and flown below the radar. They discuss the issue here:
http://www.ncbi.nlm.nih.gov/pubmed/?term=physiotherapy+cervical+adverse+event+reporting
Chiropractic is the flavour of the month on this issue but it has highlighted the need for a standardised AE reporting system across all AHPRA boards.
Mezza – adverse event reporting isn’t about blame, and it’s certainly not about shifting blame between professions. Almost all of the adverse events I’ve reported have been about fellow doctors, not others like chiropractors or physios. As an orthopaedic surgeon I have seen several patients whose treatment was delayed or irreversibly changed because their GP tried to manage something beyond their scope of practice (mostly to do with soft tissue sarcomas). The point is that adverse event monitoring allows collectively for us to ‘improve our game’, whilst identifying areas for improvement.
Perhaps what Mezza is most concerned about is what Sue Ieraci alluded to in a comment above – that a chiropractor who diagnoses an organic illness as a spinal subluxation will have misdiagnosed that patient, and if they turn out to have something harmful and significant (like a neoplastic process, cervical myelopathy, cauda equina etc) then such a montioring system might make the chiropractor more culpable. But in the end, what kind of person can call themselves a health professional if they’re not willing to have their practices held up to scrutiny?
I’m secure in the knowledge that all the orthopaedic procedures I perform have been studied in depth and incredibly well published. Unfortunately the same cannot be said of chiropractic practice.
What system do physios in private practice use? Surely it would be easiest for the same system to be rolled out for Chiros under the AHPRA.
I am in agreement that a reporting system for all health practitioners – ‘Registered’ or ‘Self Regulation’ should have such a system in place. In the ‘Self Regulation’ system we have a ‘complaints procedure’ in place, also backed by the Health Department Code of Conduct and HCCC that apply to all health practitioners (in NSW, not sure how many other States have this in place yet).
In response to the Anonymous Orthopaedic surgeon – quote”The chiropractors are not alone in cultivating such a dependency on various physical and pharmacological products at immense psychological and financial cost.” I also agree with that as well. I can only talk about my area of therapy where clients seek help that have been to practitioners with problems caused by ‘reactive past’ traumatic incidents and yet they are still undergoing treatment years later with practitioners treating the symptom rather than the cause. I believe that every General Practitioner should as part of their training read ” Adults Surviving Child Abuse 2012 Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery – Adults Surviving Child Abuse: Authors Kezelman C.A. & Stavropoulos P.A.” The download link http://www.asca.org.au/guidelines. It has been accoladed world wide, but is relevant to all people undergoing current trauma. If what we use now is working, we should be getting results.
“MezzaD” repeats the common ”defense” of denying the shortcomings of one practice by deflecting to another. This is easy to see through as others have said. The error rate in the medical system – the fallback for all healthcare of all types and all severity, and with a high cure rate, is hardly comparable to a manipulative therapy for well people with muscucloskeletal pain. In addition, adverse events are not confined to the catastorphic complications of manipulation, but also to significant misdiagnosis or delayed diagnosis. Any chiropractor that diagnooses organic illness on the basis of ”subluxations” causing ”nerve interference” is making a misdiagnosis. IF this delays effective diagnosis or treatment, harm can result. Medical practitioners are held to account for avoidable missed or incorrect diagnoses – the same should apply to all health care providers.
In Reply to Mezza,
If you look at the ABS you can see the Top 20 causes of death in Australia as recently as 2011 (http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/3303.0Chapter42011). If you look at this lnk you will see that in 2011, 147,098 people died in Australia. The leading cause of death was Ischaemic heart diseases (21,513) and the second leading cause was Cerebrovascular diseases (11,251). Your allegation of 18,000 – 54,000 deaths caused by “medical negligence, hospital-borne infections and adverse reactions to properly prescribed medications” mean that these causes would be the one of the biggest causes of death and would account for up to 37% of all deaths – which is unlikely to remain undetected. The study you cite (well website actually) uses a study from 1995 (which looked at 14,000 hospital admissions in NSW and SA) and then extrapolates to 18,000 – 54,000 deaths a year. Interestingly you omit mentioning that only half of the adverse events were preventable. I am still unsure as to why you think that severe adverse events as a possible result of chiropractic are not worth preventing?
MezzaD, we don’t have accurate statistics? Thanks for the opportunity to demonstrate open, honest and transparent reporting systems as used by medical practitioners in Australia:
http://www.ncbi.nlm.nih.gov/pubmed/7476634 A review of the medical records of over 14,000 admissions to 28 hospitals in New South Wales and South Australia revealed that 16.6% of these admissions were associated with an “adverse event”…; 51% of the adverse events were considered preventable. In 77.1% the disability had resolved within 12 months, but in 13.7% the disability was permanent and in 4.9% the patient died.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117772/#B4The Harvard and Australian studies into medical error remain the only studies that provide population level data on the rates of injuries to patients in hospitals and they identified a substantial amount of medical error
http://intqhc.oxfordjournals.org/content/15/suppl_1/i49.fullAdverse drug events and medication errors in Australia
And you really need to read and understand this link to understand the stats you’re trying to quote: http://qualitysafety.bmj.com/content/early/2012/07/24/bmjqs-2012-001368.full Deaths due to medical error: jumbo jets or just small propeller planes?
You’re welcome.
From this website http://www.medicalerroraustralia.com/ – and they are estimates because, contrary to your claim, we don’t have accurate statistics on these events in Australia. Despite the evidence of harm from medicine, your profession is gung-ho to point the bone at Chiropractic – perhaps as a way of deflecting attention from their own failures in regard to safety?
Do some people die from chiropractic? Maybe yes and maybe no. But where does the REAL risk lie?
Here is some good reading for you – if you’re really interested in the safety of medicine; the Bain Report from NZ on the safety of natural therapies-http://tinyurl.com/lgzzatc.
And since you obviously love Latin John, here is a good phrase for you from that same report – De minimis non curat lex. It means Of minimal risk importance. That was what Wallace Bain found, after an exhaustive study of this issue, to be the risk of natural therapies. And he instructed the government of NZ to stop trying to prove that natural treatments were dangerous when all the evidence pointed to the real danger being from drug-based and surgical therapies.
The issue is two fold. There is little cross communication between the doctors and the chiropractors. What I have seen at a reasonable frequency are adverse events that are neither reported to any body, nor back to the Chiropractor.
This occurs mainly where some Chiropractors, cin a significant minority, seeing themselves as primary care physicians across all areas, overreach their knowledge and experience. The patient has a significant delay in diagnosis of a serious condition, and suffers as a consequence.
There are also adverse events of omission that are seen as Nature taking its course where again some Chiropractors, cin the minority seeing themselves as advocates for natural imminuity and counselling against vaccination etc, are not implicated in the disaster of a child with a serious infectious disease which was preventable, suffering serious adverse effects with occasional life long disability.
A reporting system would not only make professionals accountable for acting against guidelines and evidence, but would also allow patients the same recourse to litigation that they have against the doctor who does not inform reasonably and obtain consent. This is not a criticism of Chiropractors, I have worked and communicated with many who work ethically and reasonably. If their profession wants recognition, and collegiality with other health professionals, then limits of experience and training in practice, adherence to evidence and accountability should be non negotiable.
In reply to MezzaD:
Read this http://en.wikipedia.org/wiki/Tu_quoque
Chiropractic needs to have a adverse event reporting system run at a national level. This should then be standardised across all the AHPRA boards. This is not about the profession, its about the PATIENT and providing them with the best, most up to date and safest evidence based care! Simple!
MezzaD, adverse events related to medical care are already captured through multiple reporting systems. The TGA has an adverse event reporting system for medicines and devices. Hospital based reporting systems capture both adverse events and near-misses. General Practice has been monitored by the BEACH system for over ten years.
Many chiropractic organisations as well as individual chiropractors claim that chiropractic care is completely safe, and that adverse events are rare. How do they know this? The point of an adverse event reporting system (AERS) is to capture that data so that an objective assessment can be made. Simply stating it ad nauseum, does not make it so.
Any intervention, medical, nursing, physiotherapy, chiropractic or otherwise carries a risk. That is the nature of health care and it is all of our responsibility as health professionals to ensure that the public can trust we are doing our best to maintain the highest standard of quality and safety.
The point of an AERS is not about blame, it is about capturing data in order to improve the quality and safety of what we do.
As an Orthopaedic surgeon now performing medicolegal examinations I have treated a complete cauda equina lesion following a chiropractic manipulation and I believe that a registry of such patients is certainly warranted. However what also concerns me is the state of psychological dependency cultivated by some chiropractors and I see quite a number of patients for assessment of compensatable injuries who have been attending chiropractors regularly for years with no apparent physical benefit. The comment “I might be worse if I do not have the treatment ” is not uncommon. The chiropractors are not alone in cultivating such a dependency on various physical and pharmacological products at immense psychological and financial cost.
MezzaD, where did you get those figures? Or should I say, where did you get the figures that you misrepresented just now? Oh that’s right – from a transparent and open reporting system, one that you clearly object to. Why? Why don’t you want to improve safety and effectiveness?
And please refrain from ignoratio elenchi arguments. In other words, argue the point being discussed and not some red herring.
You people crack me up! There are anywhere from 18,000 (conservative figure) to 54,000 (probably closer to an accurate number) Australians killed every year in the public hospital system alone by medical negligence, hospital-borne infections and adverse reactions to properly prescribed medications. And yet, you want a better system for reporting adverse events following chiropractic adjustments? How about cleaning up your own house before looking over at your neighbour’s already immaculate residence? The reporting system for medical adverse events stinks and collects only a very tiny percentage of the real number of deaths and reactions (as low as 1% according to John McEwen, formerly of ADRAC). So stop trying to erect such obvious smoke screens and look to your own failings before trying to shift the blame onto other modalities.
A problem with serious adverse events is that they will most likely not present to their treating professional, but to a hospital. A simple and inexpensive reporting system would be a simple question when a patient is admitted to the Emergency Department, “have you been treated by a let health practitioner in the last four weeks?”. This would be a screening test. If the later diagnostic codes matched the profession (eg: chiro/stroke, chinese med/poinsoning), then a more detailed examination of the practioners notes could be made. Who knows, we might find a particular manouver that is more dangerous than others?
Additionally, it is not the CAA who should be doing this. It is simply not their responsibility. It should be the CBA – the supervisory organisation – and not an industry group like the CAA. Any adverse event register run by the CAA would be immediately tainted, much like if the AMA ran one for doctors.
John Cunningham
Thankyou for the article and I agree 100% with the establishment of an adverse event reporting system for chiropractic. The gold standard would be similar to the systems in place in hospitals but that would be difficult to achieve without the same level of beaurocracy that loves to generate paper. Help from the AMA and RACGP to establish the same protocols as applied to general practitioners would be the best solution. This could then be then applied across all AHPRA boards and standardised.