Adverse events reporting in English hospital statistics: Data relevant to patient safety should not be presented alone and out of context

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. It is also setting up a patient safety observatory to draw together patient safety information from different sources, including the reporting and learning system and studies such as this one from Dr Foster. This will enable trends and patterns to be spotted, as well as identification of priorities for developing ways of reducing patient risks.

To make a highly effective and valued NHS safer for patients needs a concerted effort across a range of organisations and staff across the NHS. The National Patient Safety Agency is committed to making this happen.