An evaluation of the effectiveness of a hospital clinical adverse event prevention programme

Abstract

This is a report of a hospital based study that was conducted between January 2008 and December 2010 in the Free State Province in South Africa. The study examined the health system from a patient safety and health care services quality improvement intervention’s perspective. A key element of the research was to study the effects of the implementation of a computerised incident reporting system known as AIMS (Advanced Incident Management System) in a group of Free State hospitals. This primary intervention was implemented in the intervention sites for the first 9 months and was extended to the control sites for the last 27 months. The secondary interventions of the study were a set health care quality and patient safety culture initiatives, which together with AIMS are collectively known as AMCu (AIMS, Management and Culture interventions). These secondary interventions include the revision of incident management structures and the introduction of measures to entrench a reporting and just culture within the Free State Department of Health. These interventions were implemented in all the 31 hospitals in the Free State. Aims: This study had two key aims: 1. To determine whether a set of patient safety culture and health care quality interventions (AMCu) built around a computerised incident reporting system (AIMS) could be successfully implemented in a developing country setting. 2. To develop a hospital patient safety risk reduction model based on the existing quality frameworks and the study results for the Free State Province.