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

doi:10.1136/bmj.39031.507153.AE

BMJ, 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

Ali Baba-Akbari Sari ¹, Trevor A Sheldon ¹^*, Alison Cracknell ², Alastair Turnbull ³

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

^* Correspondence to: tas5{at}york.ac.uk.

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

DesignTwo stage retrospective review of patients' case notes and analysisof data submitted to the routine incident reporting system onthe same patients.

Setting A large NHS hospital in England.

Population1006 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).

Mainoutcome measures Proportion of admissions with at least onepatient safety incident; proportion and type of patient safetyincidents missed by routine incident reporting and case notereview methods.

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

Conclusion The routineincident reporting system may be poor at identifying patientsafety incidents, particularly those resulting in harm. Structuredcase note review may have a useful role in surveillance of routineincident reporting and associated quality improvement programmes.

(Accepted 3 November 2006)

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