A patient safety incident is an unplanned or unintended event or circumstance that could have resulted or did result in harm to a patient while in the care of a health facility (National Guideline for Patient Safety Incident Reporting and Learning in the Health Sector of South Africa 2022). The World Health Organization (2020) indicated that globally, as many as 4 out of 10 patients are harmed in primary and ambulatory care settings while receiving healthcare.

From the study conducted in England and Wales by Urquhart et al. (2021), the identifiable contributory factors for the occurrence of patient safety incidents were: failure to follow protocols, staff mistakes, a lack of active decision-making and communication between teams. Inadequate working environment and lack of staff were identified as the contributing factors to the occurrence of patient safety incidents in a study conducted at a teaching hospital in the Žilina region in Slovakia (Kohanová et al. 2023).

Li et al. (2024) revealed that leadership behaviour and job burnout contributed to patient safety incidents from their study performed at a hospital in Shiyan City, Hubei province, China. An analysis of patient safety incidents in public hospitals in Hidalgo, Mexico, (Castro-del Ángel 2024) identified patient characteristics and the application of protocols as factors contributing to patient safety incidents. The study conducted in Chilean hospitals by Dueñas et al. (2023) found that ineffective interprofessional communication, non-adherence to protocols and lack of personnel contributed to patient safety incidents. Mujuru and Peisah (2024) identified communication lapses and an implementation gap between standards and practice as the factors contributing to patient safety incidents from their study conducted at the public hospitals in Australia.

Staff factors, patient-related factors, lack of or faulty equipment, communication issues and a lack of policies and/or guidelines were identified as the contributing factors to patient safety incidents in a study conducted at the Kenyatta National Hospital in Kenya (Okutoyi et al. 2024). For South Africa, the top four contributing factors to patient safety incidents during the financial year 2022/23 were patient factor (78%), followed by staff factors (33%), work factors (17%) and organisational or service factors (13%) (National annual patient safety incidents, complaints, compliments, and suggestions report 2023). From the study conducted at a hospital in KwaZulu-Natal province in South Africa, Mgobozi and Mahomed (2021) found that patient factors, staff factors, suboptimal adherence to protocols for patient safety and inadequate equipment were the contributing factors to patient safety incidents.

Patient safety incidents can have far-reaching effects, impacting patients, healthcare workers, and healthcare systems equally. These patient safety incidents can result in physical harm, emotional trauma, and financial burdens, eventually compromising the quality of life for patients. Healthcare workers, on the other hand, may suffer from emotional distress, professional repercussions, and increased workload, probably affecting their well-being and job satisfaction. Moreover, healthcare systems may suffer significant financial costs, reputational damage, operational disruptions, and regulatory scrutiny, underscoring the necessity of robust patient safety measures. The multifaceted impact of patient safety incidents emphasises the importance for healthcare organisations to prioritise patient safety and quality care.

This study focuses on the unique challenges and contributing factors specific to Gauteng province, allowing for targeted interventions. Recognition of the contributing factors to patient safety incidents is essential for formulating focused strategies to prevent and mitigate the occurrence of these incidents. Through investigation of the causes of patient safety incidents, this research seeks to contribute to the development of safer healthcare settings and improved patient outcomes.

The results were presented under the headings: the number of questionnaires sent out and response rate from each hospital, demographic characteristics of the study population and contributing factors to patient safety incidents.

Table 2 indicates that most of the respondents were from the central hospital, with 206 respondents (90%) out of 230 questionnaires sent out. The regional hospital had a response rate of 85.33% and lastly, the district hospital had a response rate of 85%.

According to Table 3, the respondent profile indicates professional nurses formed the largest group, comprising 181 of 436 participants (41.5%). Enrolled nurses followed with 96 respondents (22.0%), and enrolled nursing assistants accounted for 72 respondents (16.5%). Operational managers nursing numbered 50 respondents (11.5%), and assistant managers nursing represented 28 participants (6.4%). Quality assurance managers constituted the smallest cohort, with 9 respondents (2.1) participating in the study.

Table 4 presents the contributing factors to patient safety incidents with work or environment factors leading at 92.72% (consumables [not available or insufficient] 94.51%, equipment [not available or not functioning] 93.30%, physical environment/infrastructure [damaged or worn or inadequate or inappropriate] 93.98% and safety or security [security systems insufficient] 89.08%), followed by organisational or service factors at 91 (staffing [staffing shortages] 96.02%, bed utilisation [unavailability of beds] 93.30%, clinical protocols or policies or procedures [not available or up to date or not approved] 89.70% and package of services [package of services not offered or cancellation or unavailability of services] 84.97%).

Patient factors were rated 90.97% (condition or disease-related factor [problems with substance abuse other mental illness, spasticity, cognitive fall outs post Cerebral Vascular Accident (CVA), existing comorbidities] 90.90% and behaviour [risky, reckless, overconfident, criminal act, attention issues (absentmindedness or forgetfulness, distraction, fatigue or exhaustion] 91.04%).

Finally, staff factors were scored 87.40% (social factors [stress, a lack of motivation, high workload, fatigue] 95.02%, human error – clinical [technical errors made while performing the procedure or not performing the clinical procedure as required] 90.66%, human error – administrative [technical error made while performing administrative procedure or not performing the administrative procedure as required] 86.01%, risky or reckless behaviour [risky, reckless due to forgetfulness, fatigue, overconfidence or criminal act] 89.22%, communication factors [language difficulties, poor communication, health literacy] 84.91% and leadership [lack of supervision, delegation of duties outside of scope of practice] 78.55%).

Work or environment factors (0.019), organisational or service factors (0.009) and staff factors (0.000) revealed statistically significant differences across the three public hospitals. Differences in hospital infrastructure, equipment, workload, staffing levels, leadership styles, communication and guidelines might be responsible for these variations in these three public hospitals.

Patient factors (0.128) did not differ significantly across the three public hospitals. These findings might be because of the similar types of health conditions or diseases prevalent among the patients across the three public hospitals.

Consumables, equipment, the physical environment, and security or safety are work or environment factors that contribute to patient safety incidents. According to Patel, Cieslak and Hertig (2023), two major healthcare supply chain issues that contribute to patient safety incidents are product delays and drug shortages. Product delays may be medical products such as active and inactive pharmaceutical ingredients, as well as syringes, gloves, masks, needles, testing materials, and other personal protective equipment. Mohammadi, Rustaee and Bijani (2023), identified lack of standard equipment and adequate physical space as the contributing factors to patient safety incidents. The physical environment (23.3%) was identified as the contributing factor to patient safety incidents (South Africa 2025:1). Unguarded doors or windows permit the patient to flee from the unit in inpatient psychiatry (Donaldson et al. 2021). Limited budgets, ageing healthcare facilities, delays in acquiring necessary supplies and equipment, and an inadequate number of security officers might be work or environment factors contributing to the patient safety incidents.

The main organisational or service factors contributing to patient safety incidents were staffing, bed utilisation, clinical protocols or policies or procedures and package of services. A shortage of human resources has been identified as a contributing factor to patient safety incidents (Halinen et al 2024). Kwobah et al. (2023), discovered that insufficient bed capacity contributes to the occurrence of patient safety incidents. Lack of clinical guidelines or protocols on patient safety management was discovered as the contributing factor to patient safety incidents (Mohammadi et al. 2023). Reported or cancelled care because of unavailable or closed services contributes to the occurrence of patient safety incidents (Fournier et al. 2021). Staff shortages, insufficient matching of staff skills to patient needs, high bed occupancy rates, outdated clinical guidelines, non-adherence to the established protocols and procedures, and the absence of needed services might be the organisational or service factors contributing to patient safety incidents.

Social factors, human error – clinical, human error – administrative, risky or reckless behaviour, communication factors and leadership were rated highly as the most staff factors contributing to the occurrence of patient safety incidents. Gauteng Department of Health report on patient safety incident contributory factors (South Africa 2025:1) showed that human error – clinical (39.2%) and human error – administrative (7.6%) contributed to patient safety incidents. Adu and Zuma (2024) revealed that the majority of the study participants linked patient safety incidents to poor communication pathways within the organisational structure and among multidisciplinary staff. Adriansyah et al. (2022), on analysis of the quality of supervision on patient safety incidents, found that poor quality of supervision led to a high incidence of patient safety incidents. This finding is corroborated by Amaniyan et al. (2020) who discovered that a lack of supervision of the work process led to patient safety incidents. Collaboration challenges, insufficient training or experience in complex clinical tasks, non-adherence to established clinical guidelines, weaknesses in administrative systems (for example, poor documentation), complacency or disregard for patient safety protocols, poor communication among healthcare teams, and insufficient strategic direction on patient safety might be the reasons for the above findings.

Condition/disease-related factor and behaviour were identified as the primary patient factors contributing to patient safety incidents. Alcohol and substance abuse and unstable mental state were identified as the contributing factors of patient safety incidents (Kwobah et al. 2023). Gauteng Department of Health report on patient safety incident contributory factors (South Africa 2025:1) showed that patient behaviour (33.6%) contributed to patient safety incidents. Patients with complex, multiple, or severe diseases might be more prone to safety incidents because of the complexity in management. The presence of multiple health issues complicates care and increases incident risk. Patients not following prescribed regimens (e.g., strict bed rest) might experience a patient safety incident.

This study identified various factors contributing to patient safety incidents, including systemic issues such as unavailability of consumables, equipment, and infrastructure, as well as human factors such as stress, fatigue, and human error. The findings also highlighted the importance of effective leadership, communication, and clinical protocols in preventing and mitigating the occurrence of patient safety incidents.

The multiplicity of these factors highlights the need for a multifaceted, focused strategic approach to enhance patient safety. Healthcare organisations must address these contributing factors through a combination of policy development, staff training, and embarking on continuous quality improvement initiatives. By understanding and addressing the root causes of patient safety incidents, healthcare providers can minimise the risk of patient safety incidents and improve patient outcomes.