The Prevalence, Severity and Nature of Adverse Events in an Inpatient Rehabilitation Hospital

Objectives: The aim of this study was to evaluate the prevalence, severity and nature of adverse events (AEs) and also suggestions to prevent AEs recurrence in an Inpatient Rehabilitation Hospital (IRH) in Iran. Methods: This retrospective descriptive-analytic was conducted in 2021, in Rofaydeh rehabilitation hospital, Tehran, Iran. AEs associated with rehabilitation services and nursing care, which were reported in the hospital’s voluntary reporting system between 2018-2021, were evaluated. A standard checklist codified by the Ministry of Health of Iran was used for collecting data from the medical error documentations. Data were analyzed by SPSS software version 21 using descriptive, Chi square and Fisher Exact tests. Results: A total of 5642 patients had been hospitalized in the study setting and 517 AEs had been documented during the four-year time period of the study. The most common AEs in order of descending were: falls 288(55.7%), pressure ulcers 57(11.02%), medication errors 50(9.67%), clinical process 49(9.47%), clinical administration (issues with admission process 10(1.93) and wrong patient identification 5(.96 %).  Among 58(11.21%) cases of hospital acquired infections, 45(77.58%) cases were Urinary tract infections (UTI). There was a significant relationship between age and fall (p=0.026), pressure ulcer (p=0.006), and hospital acquired infection (p=0.001) and between gender and fall (p=0.01), pressure ulcer (p=003), and hospital acquired infection (p=0.01). The severity of identified AEs was categorized into mild 431(83.36%), moderate 61 (11.79%) and severe 25(4.83%). The most common causes of AEs were limited supervision of patients by healthcare providers. Discussion: This study showed that patient fall, pressure ulcer and hospital acquired infection were the most prevalent AEs in rehabilitation hospital. Future efforts to improve patient safety in these settings should focus on reducing these AEs and removing barriers to voluntary incident reporting.