Incidence and Nature of Adverse Events During Inpatient Rehabilitation: A Retrospective Case Series.

Objective: The aim of the study is to describe and compare adverse event incidence, type, severity, and preventability in the Canadian inpatient rehabilitation setting.

Design: In this retrospective case series, adverse events were identified through chart reviews from two Canadian academic tertiary postacute care hospitals. Adverse events were characterized through descriptive statistics and compared using the Mantel-Haenszel and Fisher's exact tests.

Results: During the study period, one site ( n = 120) had 28 adverse events and an incidence of 9.7 (95% CI = 6.1-13.3) per 1000 patient days, and the other ( n = 48) had 15 adverse events and an incidence of 13.9 (95% CI = 6.9-21) per 1000 patient days ( P = 0.82). The two sites differed significantly in adverse event type ( P = 0.033) and preventability ( P = 0.002) but not severity. The most common adverse event type was medication/intravenous fluids-related (16/28, 57%) at one site and patient incidents (e.g., falls, pressure ulcers) at the other. Four percent (1/28) of adverse events were preventable at one site, and 53% (8/15) at another. Most adverse events at both sites were mild in severity.

Conclusions: Adverse events significantly differed in type and preventability between the two sites. These results suggest the importance of context and the need for an organization-specific and tailored approach when addressing patient safety in inpatient rehabilitation settings.