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

Objective To describe and compare adverse event (AE) incidence, type, severity, and preventability in the Canadian inpatient rehabilitation setting. Design In this retrospective case series, AEs were identified through chart reviews from two Canadian academic tertiary post-acute care hospitals. AEs 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 AEs and an incidence of 9.7 (95% CI 6.1–13.3) per 1000 patient days, and the other (n = 48) had 15 AEs and an incidence of 13.9 (95% CI 6.9–21) per 1000 patient days (p = 0.82). The two sites differed significantly in AE type (p = 0.033) and preventability (p = 0.002) but not severity. The most common AE 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 AEs were preventable at one site, and 53% (8/15) at another. Most AEs at both sites were mild in severity. Conclusions AEs 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.