BMJ  2007;334:79 (13 January), doi:10.1136/bmj.39031.507153.AE (published 15 December 2006)

Research

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review

¹ Department of Health Sciences, University of York, York YO10 5DD, ² Leeds General Infirmary, Leeds LS1 3EX, ³ York Hospital, York YO31 8HE

Objective To evaluate the performance of a routine incident reporting system in identifying patient safety incidents.

Design Two stage retrospective review of patients' case notes and analysis of data submitted to the routine incident reporting system on the same patients.

Setting A large NHS hospital in England.

Population 1006 hospital admissions between January and May 2004: surgery (n=311), general medicine (n=251), elderly care (n=184), orthopaedics (n=131), urology (n=61), and three other specialties (n=68).

Main outcome measures Proportion of admissions with at least one patient safety incident; proportion and type of patient safety incidents missed by routine incident reporting and case note review methods.

Results 324 patient safety incidents were identified in 230/1006 admissions (22.9%; 95% confidence interval 20.3% to 25.5%). 270 (83%) patient safety incidents were identified by case note review only, 21 (7%) by the routine reporting system only, and 33 (10%) by both methods. 110 admissions (10.9%; 9.0% to 12.8%) had at least one patient safety incident resulting in patient harm, all of which were detected by the case note review and six (5%) by the reporting system.

Conclusion The routine incident reporting system may be poor at identifying patient safety incidents, particularly those resulting in harm. Structured case note review may have a useful role in surveillance of routine incident reporting and associated quality improvement programmes.

Related Articles

Seeing the picture through "lean thinking"

David I Ben-Tovim
BMJ 2007 334: 169. [Extract] [Full Text] [PDF]

Routine reporting

Fiona Godlee
BMJ 2007 334: 0. [Extract] [Full Text]

Safety at what cost?

Douglas Kamerow
BMJ 2007 334: 0. [Extract] [Full Text]

Incident reporting and patient safety

Charles Vincent
BMJ 2007 334: 51. [Extract] [Full Text] [PDF]

Adverse events in British hospitals: preliminary retrospective record review

Charles Vincent, Graham Neale, and Maria Woloshynowych
BMJ 2001 322: 517-519. [Abstract] [Full Text] [PDF]

This article has been cited by other articles:

• Sari, A. B. A., Cracknell, A., Sheldon, T. A. (2008). Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review. Age Ageing 37: 265-269 [Abstract] [Full text]  
• Oliver, D. (2008). Falls risk-prediction tools for hospital inpatients. Time to put them to bed?. Age Ageing 37: 248-250 [Full text]  
• Sari, A. B.-A., Sheldon, T. A, Cracknell, A., Turnbull, A., Dobson, Y., Grant, C., Gray, W., Richardson, A. (2007). Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital. Qual Saf Health Care 16: 434-439 [Abstract] [Full text]  
• Munro, A J (2007). Hidden danger, obvious opportunity: error and risk in the management of cancer. Br. J. Radiol. 80: 955-966 [Full text]  
• Ben-Tovim, D. I (2007). Seeing the picture through "lean thinking". BMJ 334: 169-169 [Full text]  
• Vincent, C. (2007). Incident reporting and patient safety. BMJ 334: 51-51 [Full text]  

Rapid Responses:

Read all Rapid Responses

Patient safety is a symptom of our dysfunctional organisations

John Matthews
bmj.com, 21 Dec 2006 [Full text]

The incident that never happened

Christian P Subbe
bmj.com, 21 Dec 2006 [Full text]

Adverse incidents in emergency and elective patients

Ram Kumar
bmj.com, 21 Dec 2006 [Full text]

Incident reporting - but one spoke in the wheel of healthcare safety data

John H Williamson
bmj.com, 8 Jan 2007 [Full text]

Perhaps of some interest

Jeffrey C McILwain
bmj.com, 12 Jan 2007 [Full text]

Case review in practice

Grace Barden, et al.
bmj.com, 14 Jan 2007 [Full text]

Seeing the whole picture through Lean thinking eyes.

David I Ben-Tovim
bmj.com, 14 Jan 2007 [Full text]

Radiotherapy safety needs lean thinking

Katharine J Tylko, et al.
bmj.com, 16 Jan 2007 [Full text]

critical incident reporting from primary care

Mark F Lambert, et al.
bmj.com, 23 Jan 2007 [Full text]

Giving incident reporting systems a chance

Guy Haller
bmj.com, 24 Jan 2007 [Full text]