The incidence and nature of adverse events in rehabilitation inpatients with acquired brain injuries.

INTRODUCTION Patient safety is important in all healthcare settings. Few studies have examined the state of patient safety in rehabilitation and none have examined patient safety in the setting of acquired brain injury (ABI) rehabilitation. OBJECTIVES To determine the incidence, most common types, and severities of adverse events among inpatients undergoing ABI rehabilitation. DESIGN Retrospective case series descriptive study. SETTING The inpatient ABI rehabilitation program at an academic, tertiary rehabilitation hospital in Canada. PARTICIPANTS 108 consecutive inpatients with acquired brain injuries. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE(S) Patient charts and incident reports from the hospital's voluntary reporting system were reviewed by three board-certified physiatrists to determine the incidence, type, severity and preventability of adverse events. Adverse events were identified and classified for severity and type using the WHO International Classification for Patient Safety. Preventability was rated on a 6-point Likert scale. RESULTS During the study period, the incidence of adverse events was 17.42 ± 3.86 per 1000 patient days. Adverse events affected 52.8% of patients. Most adverse events identified were mild in severity (98.51%) and the rest were of moderate severity. The two most common types of adverse events were 1) patient incidents (56.72%) such as falls, pressure ulcers and skin tears, and 2) patient behaviors such as missing patient, assault, or sexual behaviors (16.42%). Of the 80 adverse events identified in the study, 44.78% were preventable. The hospital's voluntary reporting system did not capture 57.9% of the adverse events identified. CONCLUSIONS Future efforts to improve patient safety in ABI rehab should focus on reducing falls, skin injuries and behaviors, and removing barriers to voluntary incident reporting. Detecting adverse events through chart reviews provide a more complete understanding of patient safety risks in ABI rehab than relying on incident reporting alone. This article is protected by copyright. All rights reserved.