Clinician helping man walk
Safety efforts in rehabilitation hospitals typically rely on voluntary incidence reporting from care providers and primarily focus on preventing falls and skin injuries. (Photo: iStock)

A recent study led by Dr. Meiqi Guo, clinician investigator at the KITE Research Institute at UHN, provided the first detailed description of the adverse events experienced by patients admitted to a rehabilitation hospital with a brain injury.

Adverse events during a hospital stay can include issues with admission or transfer of care, delays or errors in treatment, infections acquired in the hospital, falls, patient behaviours such as assault, and issues with medical equipment or building fixtures.

To better understand the safety risks experienced by patients with a brain injury, Drs. Rouaa Mandurah, Alice Kam and Meiqi Guo from the research team reviewed the hospital records of 108 patients admitted to a rehabilitation hospital with a brain injury over a period of five months in 2017. The team also reviewed the incident reports that were filed with the hospital's voluntary incident reporting system during this period.

The team found that about half of the patients had one or more adverse events during their hospital stay. The majority of these events were considered minor and there were no severe adverse events. About half of the events were incidents such as falls and skin injuries; the rest were associated with patient behaviour such as assault and being missing, or medication-related issues.

The team identified 45 per cent of these events as preventable.

"During the study period, around half of the patients that were admitted to the rehabilitation hospital with a brain injury experienced an adverse event, with 76 events identified in total," says Dr. Guo. "By reviewing patient records, we were able to detect 75 adverse events; however, the hospital's voluntary reporting system only captured 32 adverse events – less than half of the total identified events."

Meiqi Guo
Dr. Meiqi Guo, Clinician Investigator at the KITE Research Institute at UHN, is the lead author of the study. (Photo: The KITE Research Institute at UHN)

"Patients with acquired brain injuries have complex behavioural and cognitive deficits. Our study results show that voluntary incident reporting from care providers is not enough: improved incident monitoring strategies are needed," says Dr. Guo. "With more accurate data for this group of individuals, we can take steps to better respond to safety risks in rehabilitation hospitals and improve patient safety."

A review of patients' complete hospital records is currently the best way to identify safety risks that patients with brain injuries face in rehabilitation. However, such reviews are labour-intensive and expensive to implement. To address this, researchers are now exploring the use of artificial intelligence tools to review hospital records and identify adverse events in the hospital.

This work was supported by the UHN Foundation.

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