Epidemiology of patient safety incidents in a long-term rehabilitative hospital in KwaZulu-Natal, South Africa (April 2011 to March 2016)

Abstract

Background: Patient safety is a key priority of the National Department of Health. Despite the publication of legislation and other measures to address patient safety incidents (PSIs) there are a paucity of studies relating to patient safety at the different levels of hospitals.Objectives: To determine the epidemiology (incidence, nature and root causes) of PSIs at a long-term rehabilitative hospital between April 2011 and March 2016.Method: Data were collected through a review and analysis of routinely collected hospital information on patient records and from the PSI register, as well as minutes of adverse health events meetings, quality assurance reports and patient complaints register.Results: A total or 4.12 PSIs per 10 000 inpatient days were reported. Approximately 52% of the adverse health events occurred in females with most of the adverse health events occurring in the 50–59 years category: 96% being reported during the day and 33% within the shift change. Pressure ulcers, falls, injury, hospital acquired infections and medication error were the most commonly reported PSIs. Patient factors were listed as the most common root cause for the PSIs.Conclusion: The study shows a low reporting rate of PSIs whilst showing a diverse pattern of PSIs over a period of 5 years. There is a need for active change management in order to establish a blame-free culture and learning environment to improve reporting of PSI. A comprehensive quality improvement intervention addressing patients, their families and staff is essential to minimise PSI and its consequences.

Patients for Patient Safety and Inpatients’ Perceptions of Safety in three Hospitals in Tshwane, South Africa

“…This should enhance the quality and quantity of data sources for potential safety intelligence that can be used to improve services [13]. Particularly in SA, where patient safety incidents are rarely reported and nearly every case characterizes serious damage [6,7].…”

“…These may not have been adequately shared with patients, or their provision may not have been a routine and consistent protocol in all three hospitals. Mgobozi and colleagues [7] argued that South African hospitals needed active change management to create a learning environment from patient safety incidents, improve patient reporting, implement comprehensive quality improvement interventions, and inculcate a blame-free culture. Furthermore, giving patients instructions on protective precautions during admission is considered nursing practice only in the majority of these hospitals.…”

“…HCWs perceive the following as common patient safety concerns: falls, healthcare-associated infections, laboratory errors, medication errors, misdiagnosis, patient identification and communication errors, surgical errors, postoperative complications and many others [28]. Current evidence suggests that more local contextualisation, and conceptualisation and prioritisation of patients' safety must be taken into account [4,7].…”

“…The majority of the incidents were classified as major harm [6]. Despite the mandate and regulations, most reports still lack templates for gathering statistical data that include patient participation in their own safety [7,8]. The current study aimed to determine the effectiveness of 'patients for patient safety', by assessing inpatients' awareness and involvement in their own safety and possible associations in three hospitals in Tshwane to add to the body of knowledge on the subject in the study setting.…”

Incidents related to Safety in mental health facilities in Kenya

“…The reporting rates of safety incidents is low, which means there is no strong evidence base to support to make a case for investing in interventions to promote safety (14).…”