Root cause analysis of advers events in a public hospital: a mixed-method study on reporting culture and contributing...

Patient safety is one of the fundamental priorities of healthcare services, and adverse events are among the most critical situations that threaten this safety. Effective reporting of adverse events and root cause analysis are important for healthcare systems to become learning organizations and prevent recurrence of errors. However, in Türkiye, studies analysing adverse events from both patient and staff safety perspectives remain limited, and existing research has largely focused on descriptive or single-dimensional analyses. There is a lack of comprehensive mixed-methods studies that integrate quantitative reporting data with qualitative insights into healthcare professionals' experiences.

The aim of this study is to provide a systematic and comprehensive assessment of patient and staff safety by analysing adverse event reports in a tertiary public hospital using both quantitative data and qualitative insights based on healthcare workers' experiences.

This research was planned as a mixed method and designed as a parallel mixed method. Quantitative data were obtained from the adverse event reporting system reported through the hospital management information system between 1 January and 31 December 2023 (n = 321). Qualitative data were obtained through semi-structured interview forms conducted with 10 healthcare workers selected through purposive sampling from different professional groups. Quantitative data were analysed using descriptive analyses with SPSS 25.0, while qualitative data were analysed using thematic and content analysis techniques.

A total of 321 adverse events were reported in 1 year, 35.5% of which were related to patient safety and 64.5% to staff safety. The most frequently reported types of events related to staff safety were injuries caused by sharp instruments, while those related to patient safety were reports related to the care process. Qualitative findings identified four main themes: (i) Factors Contributing to Adverse Events, (ii) Reporting Culture and Barriers, (iii) Professional Perceptions and Emotional Impacts, (iv) Systemic and Management Issues. Participants stated that adverse events were mostly caused by systemic deficiencies, that the reporting system was not functioning effectively enough due to punitive perceptions, and that witnessing or personally experiencing such events had a profound impact on their professional lives.

It is vitally important for patient safety policies to evaluate adverse events not only in numerical terms but also based on the perceptions and experiences of healthcare workers. Strengthening the reporting culture, promoting root cause analysis, ensuring psychological safety, and reducing systemic risks should be among the priority strategies for improving patient and worker safety.