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Original Research
Implementation of the patient safety incident guideline in district health services, Western Cape
Submitted: 10 January 2025 | Published: 30 April 2025
About the author(s)
Robert J. Mash, Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South AfricaKaashiefah Adamson, Division 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 Town, South Africa
Abdul Isaacs, Division 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 Town, South Africa
Gavin Hendricks, Division 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 Town, South Africa
Jani Fouche, Division 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 Town, South Africa
Jennie Morgan, Division 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 Town, South Africa
Klaus von Pressentin, Division of Family Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
Lawson Eksteen, Division 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 Town, South Africa
Leigh Wagner, Division 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 Town, South Africa
Liezel Rossouw, Division 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 Town, South Africa
Luke Profitt, Division of Family Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
Marshall Lockett, Division 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 Town, South Africa
Milton Groenewald, Division 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 Town, South Africa
Mumtaz Abbas, Division 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 Town, South Africa
Paddy Gloster, Division 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 Town, South Africa
Paul Kapp, Division 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 Town, South Africa
Stefanie Perold, Division 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 Town, South Africa
Tracey-Leigh Abrahams, Division 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 Town, South Africa
Werner Viljoen, Division 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 Town, South Africa
Abstract
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.
Keywords
Sustainable Development Goal
Metrics
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