Common Root Cause Research Articles

Identifying features of the stressed-strained state of a non-rigid roadbed along ascents and descents on highways

The object of this study is the asphalt-concrete layers of non-rigid roadbed on ascents and descents of highways before bridges. Asphalt-concrete layers of highways on approaches to bridges are one of the most important elements for providing the strength and durability of the entire structure of non-rigid roadbed. On the ascents and descents of approaches to bridges, where the speed of vehicles changes most often, the roadbed is exposed to more intense damage than in other areas. Practical experience shows that one of the most common root causes of the types of destruction of asphalt-concrete layers is disruption of their integrity in the form of cracks, which creates dangerous situations for road users due to premature and more intensive destruction of all road surfaces. This paper investigates features of the stressed-strained state of asphalt-concrete layers of roadbed on ascents and descents in the areas connecting bridges and overpasses with the embankment. A spatial finite-element model has been considered, which makes it possible to describe the stressed-strained state of each element in the road surface structure induced by the effect of traffic load on it. Quantitative and qualitative analysis of deformations, displacements, and stresses in asphalt-concrete layers of the structure of roadbed was carried out. Circumstances that can affect the premature formation of cracks and lead to a decrease in the durability of roadbed structures have been identified. This study makes it possible to identify and eliminate potential dangers that arise during the operation of roadbed. The results could be implemented in the design of roadbed in areas with difficult traffic in the area of ascent and descent, in particular before the bridge. Knowledge of features of the stressed-strained state of roadbed would contribute to the preservation of road infrastructure, could make it possible to improve the comfort and convenience when moving goods and passengers

CLUE: A CLUSTERING-BASED TEST REDUCTION APPROACH FOR SOFTWARE PRODUCT LINES

Nowadays, organizations have increasingly turned to software product lines (SPLs)/configurable systems to meet diverse user needs and market demands. SPLs offer configurability and scalability but pose a formidable challenge in testing. Assuring the quality of variants across numerous configurations demands innovative testing strategies that balance effectiveness and efficiency. To improve testing productivity, test reduction techniques have been widely employed in non-configurable code. However, test reduction for SPL systems remains mostly unexplored. This paper introduces CLUE, a novel test reduction approach to enhance testing productivity in SPLs. Our idea is that to effectively and efficiently reveal failures, tests should be distinctive and cover diverse behaviors of the system. Meanwhile, similar tests covering the same/similar behaviors of an SPL system do not need to be redundantly executed multiple times. CLUE clusters the system’s tests into distinctive groups containing similar tests. Within each cluster, tests are prioritized based on the number of feature interactions, a common root cause of defects in SPLs. CLUE continually selects and executes the top-prioritized test in each cluster until a bug is revealed or the allocated effort budget is exhausted. To evaluate CLUE, we conducted several experiments on a dataset of six widely-used SPL systems. The results show that CLUE enables developers to detect defects earlier, requiring up to 88% less effort than existing approaches. Additionally, using only 50% of the original test suites, CLUE can identify most of the bugs in the buggy SPL systems while maintaining fault localization performance.

Adverse events associated with Vibrant Soundbridge: A MAUDE study

ObjectiveTo summarize adverse events and their root causes reported to the United States Food and Drug Administration (FDA) on Vibrant Soundbridge (VSB) hearing device (Med-El, Innsbruck, Austria), an active middle ear implant for patients with moderate to severe hearing loss. Materials and methodsThe FDA's Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports of VSB adverse events from January 1, 2012, to July 27, 2022. ResultsSix hundred sixty-three total medical device reports were identified, from which 913 adverse events were extracted. Of these, 498 (54.5 %) were adverse events to patients (AEPs), while 415 (45.5 %) were device malfunctions (DMs). The most common AEPs were hearing performance issues 428 (85.9 %). The most common DMs were compromised conductive link 125 (30.1 %). Root causes identified for DMs were iatrogenic 85 (58.6 %), patient-related 28 (19.3 %), and trauma and external causes 32 (22.1 %). The most common iatrogenic root cause 12 (14.1 %) involved damage to the conductive link during revision surgery. The most common patient-related causes of DMs were excessive middle ear tissue growth 16 (57 %), and abrupt body movements 5 (28.6 %). The most common external cause of DM was cleaning of the ear canal or mastoid cavity 20 (62.5 %). ConclusionsDespite its well-known limitations, the MAUDE database provides valuable information on possible complications of VSB as it relates to device malfunction or adverse events for patients. Implementation of standardized reports with relevant and well-defined categories could certainly allow for a more meaningful analysis.

High‐frequency resonance in HVDC and wind systems: Root causes and solutions

AbstractThis paper presents methods to model and solve high‐frequency resonance problems in HVDC and wind power systems. Control and digital PWM delays are identified as a common root cause for such resonances. A systematic method to include such delays in small‐signal sequence impedance models is presented. The developed models are fully validated and used to characterize the effects of delay on system stability. In addition to full models that can predict the associated impedance and negative damping behaviour accurately, simplified approximate models are also presented to gain insights. The method is applied to type‐III and type‐IV turbines as well as HVDC converters based on modular multilevel converters (MMC). In addition to resonance of MMC and wind turbines with overhead transmission lines, the paper also identifies several other modes of high‐frequency resonance, including resonance between wind turbines and MMC HVDC converters, among different wind turbines, and between MMC HVDC converters and cables. Different methods to damp high‐frequency resonances are also discussed and demonstrated.

Surveillance of laboratory exposures to human pathogens and toxins, Canada, 2022.

The Laboratory Incident Notification Canada (LINC) surveillance system was launched in 2015 to monitor the mandated national reporting of laboratory incidents. This report describes the laboratory exposures reported in 2022. Exposure incidents were analyzed by activity, occurrence, sector, root cause and pathogens/toxins implicated, while affected individuals were analyzed by education, exposure route, role and years of laboratory experience. An analysis of the median number of exposures per month was conducted, and time between the exposure incident date and the date the incident was reported to LINC was examined. Forty confirmed laboratory exposure incident reports were received, with two suspected laboratory-acquired infections. The exposure incident rate per 100 active licences was 3.8, and the number of exposure incidents was highest in September. The majority of exposure incidents involved risk group 2 pathogens (n=27; 63%) and non-security sensitive biological agents (n=36; 84%). Microbiology was the most cited activity occurring during the exposure event (n=20; 50%), and sharps and procedure-related issues were the most common occurrences (n=15; 24.2% each). Most incidents were reported by the academic sector (n=16; 40%). Human interaction was the most common root cause (n=20; 23.8%) and most affected individuals were technicians/technologists (n=68; 73.1%). The median time delay between the incident date and reporting date was 5.5 days. The exposure incident rate was lower in 2022 than in 2021. Incidents related to sharps and standard operating procedures remained the most common occurrence types. The most cited root cause of exposure incidents involved human interaction.

Understanding the quality and evolution of Android app build systems

AbstractBuild systems are used to transform static source code into executable software. They play a crucial role in modern software development and maintenance. As such, much research effort has been invested in understanding the quality and evolution of build systems, including Apache ANT, Apache Maven, and Make‐based ones. However, the quality and evolution of build systems for mobile apps, such as on the Android platform, have not as yet been investigated in detail. Mobile app development, and the Android development context in particular, impose unique constrains, such as different device conditions and capabilities. It presents unique challenges, such as frequently upgraded Android frameworks, which those who implement and maintain build systems must tackle. In this paper, we present an exploratory empirical study of the build systems of 5222 Android projects to better understand their quality and evolution. We (a) study the build technology choices that Android developers make (Gradle being recommended and the most popular choice), (b) explore the sustainability of the official Gradle build system (parts of build files are updated more frequent that others and the update of the special Gradle plugin would induce unrecommended configurations), and (c) analyze the quality of Gradle scripts for Android apps—more than a half of the open‐source Android apps cannot be successfully built due to five common root causes.

Two waves of Kurdish politicians in exile: a comparative analysis

ABSTRACT This article provides a tour d’horizon of the recent emigration of the Kurdish political elite from Turkey and contextualizes it in its historical course. Specifically, the article discusses the similarities and differences of the exilic waves at the two ends of the chain of pro-Kurdish political parties in Turkey, i.e., the Peoples’ Democratic Party (HDP) and the Democracy Party (DEP). Based on semi-structured elite interviews, a comparison of the patterns of integration with and differentiation from the Kurdish diaspora organizations in Europe, in particular, reveals significant variation between these two exilic waves despite their common root cause. Such variation, coupled with tensions derived mainly from the hierarchal structure of the Kurdish diaspora organizations, fuels a rivalry that may alter the composition of Kurdish political elites in Europe.

Problems, causes and countermeasures of China's pension insurance system

Under the background of global population aging,, it is of great practical importance to solve the problem of old age for the growing number of elderly people and to improve their quality of life. The old-age insurance system is a state-led approach to solving the old-age problem. This paper focuses on the current situation of the operation of China's pension insurance system, and discusses it from three aspects: problems, causes, and countermeasures. The existing problems are studied from four perspectives: the gap between income and expenditure of the fund, the omission of the population covered, the unbalanced development of the three pillars, and the imperfect investment system; the causes are analyzed through the common root causes of the problems; the proposed solutions focus on the problem of funding gap, and consider both expanding sources and reducing expenditures. They should not only give full play to the government's macro-control and market supervision, but also actively use the market's ability to allocate resources to jointly promote the steady development of the endowment insurance system.

Climate Change Projection and Its Impacts on Building Façades in Singapore

Singapore is one of the most populous countries, and the majority of the population stays in high-rise public flats. In 2021, there were about 1.1 million public residential units, of which 79% were above 20 years old. The number of incidents of falling objects from a height has been increasing due to the aging and deterioration of buildings. The Periodic Façade Inspection (PFI) regime was enacted in 2020 to mandate façade inspections for all buildings above 13 m and exceeding 20 years old. However, the relatively new PFI regime has not considered the potential impacts of climate change on building façades. In this paper, the common root causes of façade defects that can be impacted by climate change are first identified. Based on the climate projection in Singapore to 2100, Singapore is expected to experience a higher mean temperature, a higher rainfall intensity, more extreme rainfall events, and a higher wind gust speed. Overall, these changes in the climate pattern will accelerate corrosion or degradation, material fatigue, adhesion failure, biological attack, and humidity or dampness. The impacts of climate change on vertical greeneries are also discussed. This paper provides a first insight into the key concerns to focus on for the future revision and improvement of the PFI regime to incorporate climate change impacts on façades.

An Empirical Study on Bugs in PHP

PHP (Hypertext Preprocessor) is a scripting language that has been widely used in web development. This paper conducts an empirical study on bugs in PHP. By analyzing 35,921 bug reports, 6524 revisions, and root causes of randomly selected 500 bugs, we find that: (1) Among all the 385 versions involved in these bugs, there are the most bugs in PHP 4.0.4, PHP 4.0.6, and PHP 4.0.3; Documentation bugs are mainly distributed in PHP 4.y.z and PHP 5.y.z; Security bugs are distributed primarily in the relatively later normal versions of PHP 5.y.z. (2) Documentation, Compile, and Scripting Engine packages are greatly affected by bugs; 73.71% of documentation bugs affect documentation; PHAR, EXIF, and GD are more affected by security bugs. (3) It may be not difficult to repair most bugs since the number of modified lines of code and files are limited; However, nearly 11% of bugs need more than one year to repair; Compared with documentation bugs, security bugs are more difficult to be repaired; The duration of bugs in PHP 8.y.z is shorter than in other versions. (4) Semantic bugs and documentation bugs are the more common root causes of bugs than others. Besides, among semantic bugs, the “Missing Features” bugs and “Processing” bugs are more than others. These results could indicate some potential problems during the detecting and repairing of PHP’s bugs. These findings reveal some laws of bugs in PHP. It could assist developers of PHP in improving their development quality, assist maintainers of PHP in detecting and repairing bugs more effectively, and suggest users of PHP evade potential risks.

Thematic mapping of perioperative incident reporting data to relational coordination domains

ABSTRACT Communication failure is a common root cause of adverse clinical events. Problematic communication domains are difficult to decipher, and communication improvement strategies are scarce. This study compared perioperative incident reports (IR) identifying potential communication failures with the results of a contemporaneous peri-operative Relational Coordination (RC) survey. We hypothesised that IR-prevalent themes would map to areas-of-weakness identified in the RC survey. Perioperative IRs filed between 2018 and 2020 (n = 6,236) were manually reviewed to identify communication failures (n = 1049). The IRs were disaggregated into seven RC theory domains and compared with the RC survey. Report disaggregation ratings demonstrated a three-way inter-rater agreement of 91.2%. Of the 1,049 communication failure-related IRs, shared knowledge deficits (n = 479, 46%) or accurate communication (n = 465, 44%) were most frequently identified. Communication frequency failures (n = 3, 0.3%) were rarely coded. Comparatively, shared knowledge was the weakest domain in the RC survey, while communication frequency was the strongest, correlating well with our IR data. Linking IR with RC domains offers a novel approach to assessing the specific elements of communication failures with an acute care facility. This approach provides a deployable mechanism to trend intra- and inter-domain progress in communication success, and develop targeted interventions to mitigate against communication failure-related adverse events.

Managing Cost Risks in Oil and Gas Construction Projects: Root Causes of Cost Overruns

This study identifies and classifies the root causes (i.e., the primary precursors) of cost overruns in oil and gas construction projects. Past studies generally focused on identifying the most immediate precursors of cost overruns and failed to address the need to identify their root causes. Specific root causes are inherent in projects with certain characteristics (e.g., projects in a particular domain or sector). Accordingly, research is needed to identify various cost overrun factors and their root causes in a context-specific manner. This study used content analysis to identify 38 recurrent cost overrun factors and 11 root causes in oil and gas construction projects. The cost overrun factors were classified based on their common root causes. The Delphi method was used to verify this classification. The evidence from 12 construction projects in the oil and gas sector that had faced cost overruns was used to verify the outcome of this study. The findings of the study will assist practitioners in mitigating the risk of cost overruns in oil and gas projects and meeting their budget goals.

Evaluating medical students’ ability to identify and report errors: finding gaps in patient safety education

ABSTRACT Background Although there are frequent complaints of medical students’ incompetence in reporting errors, few studies have examined their error-reporting abilities in the real world. Objectives Three sub-functions of self-regulation theory were used to evaluate medical students’ ability to identify errors (self-monitoring), analyse root causes (self-judgment), and devise improvement plans (self-reactions). In addition, whether students reacted differently to their errors and those of others (three sub-functions) was also examined. Methods A total of 952 patient safety reports were reviewed retrospectively, submitted by third-year medical students between 2016 and 2018. Data were quantitatively and qualitatively analysed to investigate who committed the error, to identify the type of error and its root causes, and to find suggested improvement plans. Chi-square and Fisher’s exact tests were used to compare students’ responses to error origins. Results Students reported other errors more frequently than their own (67.6% vs. 32.4%). They reported common critical medical errors, including errors related to engaging with patients (34.5%), invasive procedures (20.2%), and infection (18.5%). The root causes identified were more precise than the improvement plans by the students (75.5% vs. 18.4%, respectively). The students’ improvement plans were not practical, especially at the patient level (25.8%). When students committed errors, they considered human factors such as fatigue, scheduling, and training as the most common root cause, focussing on improvement plans at the individual level. Conclusions The results suggest that students were good at self-judgment, but not at self-monitoring and self-reactions. They reacted differently, based on who committed the error. To enhance self-regulated learning, Educators should encourage students to confront their errors, reflect on their self-reactions towards errors, develop well-being with time management, and think about the meaning of patient-centredness. Finally, active participation in clinical clerkship longitudinally may provide students with opportunities to learn from their errors.

Landscape injustices in polarised communities: unearthing perceptions at Sitia UNESCO Geopark, Greece

ABSTRACT Local planning conflicts can stem from perceived inherent landscape injustice. This article explores how conflicting community perceptions of such injustice can be analysed through local collaborative decision-making processes. A theoretical framework to analyse landscape injustice is proposed and applied to the Sitia UNESCO Geopark (East Crete, Greece). This paper thus examines whether, as part of the knowledge formation processes for the holistic treatment of landscape, landscape planning should explicitly analyse landscape visions, values, threats and injustice at a local community scale, and explores how their explicit consideration can contribute to planning processes in polarised communities. The case study results indicated that polarised (pro-environment vs pro-development) community stakeholders shared visions and values of their ideal landscape, including common root causes of perceived injustice. The analysis of landscape injustice revealed state and external interventions leading to local people’s loss of land ownership and procedural marginalisation from decision-making processes regarding the landscape and its future use.

Surveillance of laboratory exposures to human pathogens and toxins, Canada 2020.

The Laboratory Incident Notification Canada surveillance system monitors laboratory incidents reported under the Human Pathogens and Toxins Act and the Human Pathogens and Toxins Regulations. The objective of this report is to describe laboratory exposures that were reported in Canada in 2020 and the individuals who were affected. Laboratory incident exposures occurring in licensed Canadian laboratories in 2020 were analyzed. The exposure incident rate was calculated and the descriptive statistics were performed. Exposure incidents were analyzed by sector, activity type, occurrence type, root cause and pathogen/toxin. Affected persons were analyzed by education, route of exposure sector, role and laboratory experience. The time between the incident and the reporting date was also analyzed. Forty-two incidents involving 57 individuals were reported to Laboratory Incident Notification Canada in 2020. There were no suspected or confirmed laboratory acquired infections. The annual incident exposure rate was 4.2 incidents per 100 active licenses. Most exposure incidents occurred during microbiology activities (n=22, 52.4%) and/or were reported by the hospital sector (n=19, 45.2%). Procedural issues (n=16, 27.1%) and sharps-related incidents (n=13, 22.0%) were the most common occurrences. Most affected individuals were exposed via inhalation (n=28, 49.1%) and worked as technicians or technologists (n=36, 63.2%). Issues with standard operating procedures was the most common root cause (n=24, 27.0%), followed by human interactions (n=21, 23.6%). The median number of days between the incident and the reporting date was six days. The rate of laboratory incidents were lower in 2020 than 2019, although the ongoing pandemic may have contributed to this decrease because of the closure of non-essential workplaces, including laboratories, for a portion of the year. The most common occurrence type was procedural while issues with not complying to standard operating procedures and human interactions as the most cited root causes.

Complex Trauma Care Pathway: Results of a 12-Month Pilot.

Sustained, developmentally adverse experiences in childhood put survivors at risk for posttraumatic stress disorder and impairments in biological, affective, cognitive, and intra/interpersonal domains. Complex trauma symptoms are often treated in isolation without addressing their common root cause. The trauma-focused phased Complex Trauma Care Pathway (CTCP) was developed to address this care gap. We piloted the CTCP in 2 medical centers for 12 months among 46 therapist-referred adults. Outcome measures collected every 3 months included standardized scales assessing anxiety, depression, suicidal thoughts, and disorders of extreme stress not otherwise specified (DESNOS). Statistically significant improvements occurred in mean scores for anxiety (p = 0.003), total DESNOS scores (p < 0.001), and 5 DESNOS domains: alterations in regulation of affect and impulses, alterations in regulation of attention or consciousness, alterations in self-perception, alterations in relationships with others (p < 0.001 for all), and alterations in systems of meaning (p = 0.006). In contrast, decreases in symptoms of somatization, depression, substance use, and suicidal thoughts were not statistically significant. Participant feedback was very positive. Many trials evaluate phased interventions for posttraumatic stress disorder, but much less evidence exists about effective interventions for complex trauma. Our study fills a knowledge gap. The CTCP shows promising clinical efficacy and should be evaluated using a more rigorous design. Further research should also explore the relationship between the CTCP or similar interventions and chronic disease management, overall healthcare utilization, and suicide risk.

Tau phosphorylation and OPA1 proteolysis are unrelated events: Implications for Alzheimer's Disease

The neuropathological hallmarks of Alzheimer's Disease are plaques and neurofibrillary tangles. Yet, Alzheimer's is a complex disease with many contributing factors, such as energy-metabolic changes, which have been documented in autopsy brains from individuals with Alzheimer's and animal disease models alike. One conceivable explanation is that the interplay of age-related extracellular and intracellular alterations pertaining to Alzheimer's, such as cerebrovascular changes, protein aggregates and inflammation, evoke a mitochondrial response. However, it is not clear if and how mitochondria can contribute to Alzheimer's pathophysiology. This study focuses on one particular aspect of this question by investigating the functional interaction between the microtubule-associated protein tau and the mitochondrial inner membrane fusion machinery, which shows alterations in Alzheimer's brains. OPA1 is an essential inner membrane-fusion protein regulated by the two membrane proteases OMA1 and YME1L1. Assessment of OPA1 proteolysis—usually found in dividing mitochondria—and posttranslational tau modifications in mouse and human neuroblastoma cells under different experimental conditions clarified the relationship between these two pathways: OPA1 hydrolysis and phosphorylation or dephosphorylation of tau may coincide, but are not causally related. OPA1 cleavage did not alter tau's phosphorylation pattern. Conversely, tau's phosphorylation state did not induce nor correlate with OPA1 proteolysis. These results irrefutably demonstrate that there is no direct functional interaction between posttranslational tau modifications and the regulation of the OMA1-OPA1 pathway, which implies a common root cause modulating both pathways in Alzheimer's.

The Impact of Material Management on Construction Project Delivery in Somalia

Materials management practice is a procedurethat coordinates planning, requirement assessment,sourcing, purchasing, transporting, materials storing and controlling, wastage minimisationand cost reduction for profit optimization.Material management have been a great problem to most firms in the construction industrydue to a tendency of mismanagement of materials.The scale of activities concerning materials managementincreases as the size of the contract increase.Thisstudycentered on the impact of materials management practices in the Somaliaconstruction project delivery.The objectives ofthis studyaretoinvestigate the current practice of material management at construction projects, to identify the causes of ineffective material management, and to examine the impact of material management process to the construction project delivery.A questionnaire survey was conducted to collect data from Grade A contractor company in Mogadishu, Somalia and the respondent consist of project managers, civil engineers, architect and site managers. The findings revealed that current practice of material management in construction projects in Somalia include identifying the needed materials, consideration of site layout and location, materialavailableclose to site, material conformwith specifications and material supplied on-time. The studyalsofound thatmost common root causes of ineffective material management were undefined scope, incomplete drawings, inadequate information on material supply, poor scheduling of material on site, nodetermination ofwhat and whenthe material needed and lack indeterminingthe quantity of material needed. Furthermore, the respondents of this research indicated that the occurrence of cost overrun and delay in progress of the work are the major impacts of ineffective material management thatbring negative impact to the construction project delivery in Somalia. The research concludes that effective material management practice can improve the overall handling of material and smooth project delivery on site.Aproper planning of material management practice right from the start of the project execution should be practiced on site in order to ensure timely execution of the project and standard of the work delivery within reasonable cost, time and quality.

Root Cause Analysis of Adverse Events Involving Opioid Overdoses in the Veterans Health Administration

ObjectiveThe Veterans Health Administration (VHA) serves a population with compounding risk factors for opioid misuse, including chronic pain, substance use disorders, and mental health conditions. The objective of this study was to analyze opioid-related adverse events and root causes to inform mitigation strategies associated with opioid prescribing and administration. MethodsThe researchers conducted a retrospective analysis of root cause analysis reports of opioid overdose events between August 1, 2012, and September 30, 2019. These adverse events were investigated locally by multidisciplinary hospital teams and reported by VHA facility patient safety managers to the National Center for Patient Safety for further aggregation and analysis. Type of event, location, and root causes were categorized. ResultsEighty-two adverse event reports were identified. Patients were primarily male with an average age of 61.4 years. Staff medication administration errors were the most common event type (57.3%), with most events resulting from process errors (65.9%) occurring in the health care setting (85.4%). Overall 36 events (43.9%) resulted in major or catastrophic harm. There were 172 root causes identified. The most common root causes were staff not following existing policy or lack of existing hospital policy on opioid management (18.0%); staff lacked training in areas such as managing the use or administration of opioids, correct use of opioid dispensing equipment, and recognition and proper response to an overdose (12.2%); and poor communication of opioid prescribing or administration during handoffs between clinical teams (11.6%). A lack of standardization in processes, training, and policies on opioid prescribing and screening, medication administration, equipment/pumps purchase and use, and contraband searches was a common theme throughout. ConclusionErrors in prescribing and administration of opioid medication can result in significant harm. A lack of standardized opioid administration practices and training, controlled substance policies, and interdisciplinary communication were frequent factors in adverse opioid events and should be a focus for future prevention.

Epidemiology of patient safety incidents in a long-term rehabilitative hospital in KwaZulu-Natal, South Africa (April 2011 to March 2016).

BackgroundPatient safety is a key priority of the National Department of Health. Despite the publication of legislation and other measures to address patient safety incidents (PSIs) there are a paucity of studies relating to patient safety at the different levels of hospitals.ObjectivesTo determine the epidemiology (incidence, nature and root causes) of PSIs at a long-term rehabilitative hospital between April 2011 and March 2016.MethodData were collected through a review and analysis of routinely collected hospital information on patient records and from the PSI register, as well as minutes of adverse health events meetings, quality assurance reports and patient complaints register.ResultsA total or 4.12 PSIs per 10 000 inpatient days were reported. Approximately 52% of the adverse health events occurred in females with most of the adverse health events occurring in the 50–59 years category: 96% being reported during the day and 33% within the shift change. Pressure ulcers, falls, injury, hospital acquired infections and medication error were the most commonly reported PSIs. Patient factors were listed as the most common root cause for the PSIs.ConclusionThe study shows a low reporting rate of PSIs whilst showing a diverse pattern of PSIs over a period of 5 years. There is a need for active change management in order to establish a blame-free culture and learning environment to improve reporting of PSI. A comprehensive quality improvement intervention addressing patients, their families and staff is essential to minimise PSI and its consequences.