# Implementation of the patient safety incident guideline in district health services, Western Cape

## TL;DR

This study evaluates how well a patient safety reporting system was implemented in health services in the Western Cape, South Africa.

## Contribution

The study provides insights into the implementation challenges and outcomes of a new patient safety reporting system in district health services.

## Key findings

- 577 patient safety incidents were reported across 16 facilities in 2023.
- Most incidents occurred in hospital wards and were reported by health professionals.
- Training and infrastructure improvements are needed for long-term success.

## Abstract

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.

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.

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.

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.

The need for continuous training, awareness and systemic improvements to enhance the effectiveness of PSIRLS in South African district health services.