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.