Epidemiology of patient safety incidents in a long-term rehabilitative hospital in KwaZulu-Natal, South Africa (April 2011 to March 2016).
Phe Mgobozi, Ozayr H Mahomed
PMID 34082537WHAT IT FOUND
110 reported patient safety incidents occurred among 831 admissions at a long-term rehabilitation hospital.
Pressure ulcers, falls, injury and infection were common; most were moderate, and patient factors were main contributors.
Key findings
01A total of 110 PSIs fulfilled the inclusion criteria, representing 13% of patients admitted.
02The most common reported incidents were pressure ulcers 32.0%, falls 24.0%, injury 29.0%, hospital acquired infections 11.0% and medication error 5.4%.
03Most incidents were moderate 54.0% or minor 37.0%, and permanent disability or death was reported in 2.8%.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The incidents were voluntarily reported, so the counts are likely incomplete. Data were collected for routine clinical care, not research, with gaps, illegible entries and inconsistent recording. The study was done in one long-term step-down rehabilitation hospital, so patterns may not match acute hospitals. Reporting processes changed during the study period, which may affect year-to-year comparisons. The authors note low reporting could reflect reluctance to report incidents.
The easy way to misread this
Do not read the reported incidents as the full burden of patient harm. The authors state voluntary reporting collects only a small proportion of adverse events, and some incidents were only found in meeting minutes rather than as reported PSIs.