BMJ  2004;329:857 (9 October), doi:10.1136/bmj.329.7470.857

Letter

Adverse events reporting in English hospital statistics

Data relevant to patient safety should not be presented alone and out of context

The first 150 words of the full text of this article appear below.

EDITOR—The publication of Dr Foster's case notes has generated considerable interest,¹ but accurately quantifying patient safety incidents is difficult. Methods of intensive case note review provide estimates of adverse events in acute hospitals that range from 2.9% to 16.6%, but definitions, methods, and health systems vary.^{2 3}

The National Patient Safety Agency fully supports Dr Foster's conclusion that hospitals should be encouraged to report incidents. However, a full picture of patients' safety is not possible from any one data source: information is needed from a range of sources for an accurate picture.

Furthermore, Dr Foster's analysis tells us nothing about what we need to change to improve safety. Including data from systems that collect information on causes and prevention will be needed to support improvement in patient safety.

The National Patient Safety Agency has developed a national reporting and learning system to enable healthcare staff to report incidents anonymously. . . . [Full text of this article]

National Patient Safety Agency, London W1T 5HD Richard.thomson@npsa.nhs.uk

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