As a speech-language professional, what’s the first medical error that comes to mind when you think of a critical incident? Most likely, not a hernia operation. The Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, documented the following case of a routine hernia surgery resulting in a TIA, aspiration and ultimately death:
An elderly man, post hernia surgery, had a transient ischemic attack (TIA) and respiratory difficulties. His speech prior to surgery had been normal but was now slurred. He was also choking on thin liquids. The neurologist examined the patient and recommended a swallowing study. A speech-language pathologist (SLP) evaluated the patient, found him to be at high risk for aspiration, and completed a consultation form recommending NPO status. However, the physician did not see the form, and the patient continued to receive thickened liquids. Two days later, the patient suddenly aspirated, arrested, and died.
Within one hour of the patient’s death, the hospital reviewed the case. The critical incident resulted in changes to the protocol for swallowing evaluations. As part of the updated protocol, the physician “pre-authorizes” an NPO order, and the SLP is authorized to write the NPO order if the bedside swallowing evaluation is suspicious for the risk of aspiration. However, the deadly outcome for this patient had already occurred.
The AHRQ documentation detailed a number of reasons for this tragic error. As in most medical errors, the failure cannot be attributed to a single party. In this case, the critical error had its roots in the failure of both written and verbal communication. First, the SLP did not consider the NPO recommendation important enough to contact the physician immediately, and thus she did not verbally communicate the recommendation to the physician. Second, the hospital protocol resulted in sequestering her consultation form with the NPO recommendation in a special section of the chart, not in the core daily progress notes that all physicians read regularly. Third, the physician did not read the SLP’s consultation form and act upon the recommendation.
The AHRQ commentary further notes, “Medical errors and accidents due to communication mishaps are complex and multifaceted. In this case, liability could be attributed to the physician, the speech therapist, and the nurses caring for the patient. All of them failed to communicate and/or receive critical medical information, and their failure led to the patient’s aspiration. This means that we need to be careful that, after an accident investigation or root-cause analysis, we don’t design protocols that prevent only the specific error from happening again. In this case, an NPO order was the problem, but the root cause analysis revealed general problems with communication. The chance that another patient will die due to lack of a timely NPO order is relatively small.
However, the chance that problems in inter-professional communication will cause other adverse events is high. The institution needs to make sure it does something about the latter, not just the former.”
The Joint Commission Safety Goals include a number of recommended steps to prevent error. Of these, “to improve the effectiveness of caregiver communication” is the one identified by ASHA (2010a) in its website publication, Patient Safety and the SLP (http://www.asha.org/slp/PatientSafety.htm), as the one that affects SLPs and audiologists the most. “This goal requires implementing a process of verifying verbal or telephone orders by having the individual receiving the order read it back.”
Virtually all of the consumers (96%) said hospitals should be required to report medical errors to state health departments. Currently most states (including Florida) do not disclose facility-specific information to the public about mistakes. Yet 82% want each hospital’s medical error record to be available to the public. According to a study in Health Affairs (Classsen et al., 2011), hospital errors are more common than suspected…ten times more common. Medical errors and other adverse events occur in one-third of hospital admissions according to the authors. The more you look for errors, the more you will find.
Preventing Medical Errors in Speech-Language Pathology is a 2-hour online continuing education (CE) course that examines how medical errors can be prevented in the practice of speech-language pathology.
The intent of this course is to include all of the elements required for an approved medical errors course for speech-language pathologists (SLPs) and audiologists, including topics and case examples that will resonate with both novice and seasoned clinicians. It is a required course for Florida licensees and satisfies their biennial requirement. It is intended to be of clinical interest to all SLPs and audiologists who wish to increase their awareness of the ways in which patients can be harmed and the many strategies for anticipating and avoiding such undesirable outcomes.
This course addresses the impact of medical errors on today’s health care with a focus on root cause analysis, error reduction and prevention, and patient safety. Multiple scenarios of real and potential errors in the practice of speech-language pathology and audiology across the continuum of practice are included, along with recommended strategies for preventing them. Evidence shows that the most effective error prevention occurs when a partnership exists among care facilities, health care professionals, and the patients they treat.
* This course satisfies the medical errors requirement for biennial relicensure of Florida speech-language pathologists and audiologists.
Course #21-61 | 2025 | 52 pages | 15 posttest questions | Mobile-Friendly
Course Directions
This online course provides instant access to the course materials and CE test. The course is text-based (reading), and the CE test is open-book (you can print the test to mark your answers on it while reading the course materials).
Successful completion of this course involves passing an online test (80% required, 3 chances to take) and we ask that you also complete a brief course evaluation.
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Professional Development Resources is a nonprofit educational corporation 501(c)(3) organized in 1992. We are approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. Professional Development Resources maintains responsibility for all programs and content. Professional Development Resources is also approved by the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB Provider #1046, ACE Program); the Continuing Education Board of the American Speech-Language-Hearing Association (ASHA Provider #AAUM); the American Occupational Therapy Association (AOTA Provider #3159); the Commission on Dietetic Registration (CDR Prior Approval Program); the New York State Education Department’s State Board for Psychology as an approved provider of continuing education for licensed psychologists (#PSY-0145), State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors (#MHC-0135) and marriage and family therapists (#MFT-0100), and the State Board for Social Workers as an approved provider of continuing education for licensed social workers (#SW-0664); the Texas Board of Examiners of Marriage and Family Therapists (#114) and State Board of Social Worker Examiners (#5678); and is CE Broker compliant (#50-1635 – all courses are reported within two business days of completion).
PDR offers over 150 accredited online CE courses for healthcare professionals.
Target Audience: Psychologists, School Psychologists, Counselors, Social Workers, Marriage & Family Therapists (MFTs), Speech-Language Pathologists (SLPs), Occupational Therapists (OTs), Registered Dietitian Nutritionists (RDNs), and Teachers
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