Implementation of the patient safety incident guideline in district health services, Western Cape
Background: South Africa has implemented a patient safety incident reporting and learning system (PSIRLS) in 2022. The aim of this study was to evaluate the implementation of this PSIRLS in the district health services of the Western Cape. Methods: A convergent parallel mixed methods study was cond...
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| Format: | Article |
| Language: | English |
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AOSIS
2025-04-01
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| Series: | South African Family Practice |
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| Online Access: | https://safpj.co.za/index.php/safpj/article/view/6108 |
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| author | Robert J. Mash Kaashiefah Adamson Abdul Isaacs Gavin Hendricks Jani Fouche Jennie Morgan Klaus von Pressentin Lawson Eksteen Leigh Wagner Liezel Rossouw Luke Profitt Marshall Lockett Milton Groenewald Mumtaz Abbas Paddy Gloster Paul Kapp Stefanie Perold Tracey-Leigh Abrahams Werner Viljoen |
| author_facet | Robert J. Mash Kaashiefah Adamson Abdul Isaacs Gavin Hendricks Jani Fouche Jennie Morgan Klaus von Pressentin Lawson Eksteen Leigh Wagner Liezel Rossouw Luke Profitt Marshall Lockett Milton Groenewald Mumtaz Abbas Paddy Gloster Paul Kapp Stefanie Perold Tracey-Leigh Abrahams Werner Viljoen |
| author_sort | Robert J. Mash |
| collection | DOAJ |
| description | Background: South Africa has implemented a patient safety incident reporting and learning system (PSIRLS) in 2022. The aim of this study was to evaluate the implementation of this PSIRLS in the district health services of the Western Cape.
Methods: A convergent parallel mixed methods study was conducted within a practice-based research network. Qualitative data were collected through 15 semi-structured interviews with purposefully selected respondents from 10 district hospitals and 5 primary care facilities, and the data were thematically analysed. Quantitative data for 2023 were collected from the PSIRLS at 16 facilities and analysed descriptively.
Results: The PSIRLS was adopted by all facilities. Overall, 577 patient safety incidents (PSI) were reported (range 0–148 per facility) with 91% from district hospitals, 18% severity assessment code 1 (SAC1), 33% caused harm and 72% in hospital wards. Staff were prompted to follow the steps by structured forms and the digital system. Patient safety incidents were reported by health professionals, although clinicians were concerned about blame and damaging teamwork. Severity assessment code 1 were reported on time (median 24 h) and investigated promptly (median closure 4 days). Opportunity costs could be significant. While the system improved patient safety, it primarily focussed on behavioural interventions. Austerity measures and the reduction of quality assurance managers posed a threat to the system.
Conclusion: Strengthening training for operational managers and clinical staff, enhancing infrastructure and addressing mental health-related incidents are crucial for long-term success. Future research should explore sustainable strategies to overcome financial and organisational barriers.
Contribution: The need for continuous training, awareness and systemic improvements to enhance the effectiveness of PSIRLS in South African district health services. |
| format | Article |
| id | doaj-art-29e65bf7b4a5459e97d9d67dc4437a5b |
| institution | DOAJ |
| issn | 2078-6190 2078-6204 |
| language | English |
| publishDate | 2025-04-01 |
| publisher | AOSIS |
| record_format | Article |
| series | South African Family Practice |
| spelling | doaj-art-29e65bf7b4a5459e97d9d67dc4437a5b2025-08-20T03:06:52ZengAOSISSouth African Family Practice2078-61902078-62042025-04-01671e1e1210.4102/safp.v67i1.61084941Implementation of the patient safety incident guideline in district health services, Western CapeRobert J. Mash0Kaashiefah Adamson1Abdul Isaacs2Gavin Hendricks3Jani Fouche4Jennie Morgan5Klaus von Pressentin6Lawson Eksteen7Leigh Wagner8Liezel Rossouw9Luke Profitt10Marshall Lockett11Milton Groenewald12Mumtaz Abbas13Paddy Gloster14Paul Kapp15Stefanie Perold16Tracey-Leigh Abrahams17Werner Viljoen18Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape TownDivision of Family Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; and, Metro Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; and, Metro Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Rural Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Rural Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; and, Metro Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Rural Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Metro Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Rural Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape TownDivision of Family Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; and, Metro Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Rural Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Metro Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Rural Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Rural Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Rural Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Metro Health Services, Western Cape Department of Health and Wellness, Cape TownDivision of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Metro Health Services, Western Cape Department of Health and Wellness, Cape TownBackground: South Africa has implemented a patient safety incident reporting and learning system (PSIRLS) in 2022. The aim of this study was to evaluate the implementation of this PSIRLS in the district health services of the Western Cape. Methods: A convergent parallel mixed methods study was conducted within a practice-based research network. Qualitative data were collected through 15 semi-structured interviews with purposefully selected respondents from 10 district hospitals and 5 primary care facilities, and the data were thematically analysed. Quantitative data for 2023 were collected from the PSIRLS at 16 facilities and analysed descriptively. Results: The PSIRLS was adopted by all facilities. Overall, 577 patient safety incidents (PSI) were reported (range 0–148 per facility) with 91% from district hospitals, 18% severity assessment code 1 (SAC1), 33% caused harm and 72% in hospital wards. Staff were prompted to follow the steps by structured forms and the digital system. Patient safety incidents were reported by health professionals, although clinicians were concerned about blame and damaging teamwork. Severity assessment code 1 were reported on time (median 24 h) and investigated promptly (median closure 4 days). Opportunity costs could be significant. While the system improved patient safety, it primarily focussed on behavioural interventions. Austerity measures and the reduction of quality assurance managers posed a threat to the system. Conclusion: Strengthening training for operational managers and clinical staff, enhancing infrastructure and addressing mental health-related incidents are crucial for long-term success. Future research should explore sustainable strategies to overcome financial and organisational barriers. Contribution: The need for continuous training, awareness and systemic improvements to enhance the effectiveness of PSIRLS in South African district health services.https://safpj.co.za/index.php/safpj/article/view/6108patient safetyprimary caredistrict hospitalsrisk managementpatient safety incidents. |
| spellingShingle | Robert J. Mash Kaashiefah Adamson Abdul Isaacs Gavin Hendricks Jani Fouche Jennie Morgan Klaus von Pressentin Lawson Eksteen Leigh Wagner Liezel Rossouw Luke Profitt Marshall Lockett Milton Groenewald Mumtaz Abbas Paddy Gloster Paul Kapp Stefanie Perold Tracey-Leigh Abrahams Werner Viljoen Implementation of the patient safety incident guideline in district health services, Western Cape South African Family Practice patient safety primary care district hospitals risk management patient safety incidents. |
| title | Implementation of the patient safety incident guideline in district health services, Western Cape |
| title_full | Implementation of the patient safety incident guideline in district health services, Western Cape |
| title_fullStr | Implementation of the patient safety incident guideline in district health services, Western Cape |
| title_full_unstemmed | Implementation of the patient safety incident guideline in district health services, Western Cape |
| title_short | Implementation of the patient safety incident guideline in district health services, Western Cape |
| title_sort | implementation of the patient safety incident guideline in district health services western cape |
| topic | patient safety primary care district hospitals risk management patient safety incidents. |
| url | https://safpj.co.za/index.php/safpj/article/view/6108 |
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