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

Objectives: This study aims to evaluate the prevalence, severity, and nature of adverse events (AEs) and provide suggestions on how to prevent AEs recurrence in an inpatient rehabilitation hospital in Iran. Methods: This retrospective descriptive-analytical study was conducted in ۲۰۲۱ at Rofaydeh Rehabilitation Hospital in Tehran City, Iran. AEs associated with rehabilitation services and nursing care, which were reported in the hospital’s voluntary reporting system from ۲۰۱۸ to ۲۰۲۱ were evaluated. A standard checklist codified by the Ministry of Health of Iran was used to collect the data from the medical error documentation. The data were analyzed by the SPSS software, version ۲۱, using descriptive statistics, the chi-square, and the Fisher exact tests. Results: A total of ۵۶۴۲ patients had been hospitalized in the study setting and ۵۱۷ AEs had been documented during the ۴ years of the study. The most common AEs in descending order were as follows: falls ۲۸۸(۵۵.۷%), pressure ulcers ۵۷(۱۱.۰۲%), medication errors ۵۰(۹.۶۷%), clinical process ۴۹(۹.۴۷%), clinical administration (issues with admission process ۱۰(۱.۹۳%) and wrong patient identification ۵(۰.۹۶%). Among ۵۸(۱۱.۲۱%) cases of hospital-acquired infections, ۴۵(۷۷.۵۸%) cases were urinary tract infections. There was a significant relationship between age and fall (P=۰.۰۲۶), pressure ulcer (P=۰.۰۰۶), and hospital-acquired infection (P=۰.۰۰۱), and between gender and fall (P=۰.۰۱), pressure ulcer (P=۰۰۳), and hospital-acquired infection (P=۰.۰۱). The severity of identified AEs was categorized into mild ۴۳۱(۸۳.۳۶%), moderate ۶۱(۱۱.۷۹%), and severe ۲۵(۴.۸۳%). 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 the rehabilitation hospital. Future efforts to improve patient safety in these settings should focus on reducing such AEs along with removing barriers to voluntary incident reporting. Coresponding author: Hamid Reza Khankeh, E-mail: ha.khankeh@uswr.ac.ir You can also search for this author in:  PubMed, Google Scholar