Analysis of adverse events must result in improvements in care

See also p 1413

EDITOR—In his editorial on medical errors Alberti mentions studies of adverse events from Australia and the United States.1 He then welcomes a paper by Vincent et al2: “Finally, we now have some British data from London based on retrospective record reviews” (of 1014 patients in two acute hospitals in London).

In 1980 colleagues and I published a detailed audit of adverse events occurring in 2607 inpatients treated by one surgical firm at the Radcliffe Infirmary in 1978.3 Major, moderate, and minor adverse events in adults and children were recorded prospectively, and we made suggestions (which we hoped would be noted by clinicians and administrators) that might encourage wider adoption of this type of investigation so that clinical care might be improved.

In 1990 I wrote an editorial in the BMJ on the findings of the 1989 national confidential enquiry into perioperative deaths (within 30 days of surgery) among children aged under 11.4 The editorial's concluding sentence was: “If clinical information services are improved … then an even more formidable task may lie ahead: the investigation of perioperative morbidity.”

In 2000, England's chief medical officer suggested that a national system for recording adverse events should be set up.5 This suggestion has Alberti's support, although he describes it as an enormous undertaking. I hope that we will not have to wait yet another decade before the analysis of data concerning adverse events leads to action being taken to improve care. Prompt action by the Department of Health to provide the resources necessary for this initiative would go some way to compensate for the previous delays.

Organisational ethos is important

EDITOR—Alberti highlights the possible magnitude of the problem facing the NHS with regard to medical error, but he makes little mention of clinical governance.1 In its …