Adverse events in British hospitals: preliminary retrospective record reviewBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7285.517 (Published 03 March 2001) Cite this as: BMJ 2001;322:517
An adverse event is "an unintended injury caused by medical management rather than by the disease process and which is sufficiently serious to lead to prolongation of hospitalisation or to temporary or permanent impairment or disability to the patient at time of discharge"
• Medical management includes both the actions of an individual member of staff or the overall health care system.
• Medical management includes acts of omission (for example, failure to diagnose or treat) and commission (for example, incorrect treatment).
• Causation of adverse event by medical management was judged on a six point scale, where 1 indicates "virtually no evidence for management causation" and 6 indicates "virtually certain evidence for management causation." Only adverse events with a score of 4 or higher, requiring evidence that causation is more likely than not, are reported in the results.
• Adverse events may or may not be preventable; the judgment is separate from that of causation. Preventability was also judged on a six point scale, with only those adverse events scoring 4 or higher being considered preventable.
• Injury may result from intervention or from failure to intervene. Although this is not always made clear, injuries that come about from failure to arrest the disease process are also included provided that standard care would clearly have prevented the injury.
• The injury has to be unintended, since injury can occur deliberately and with good reason (for example, amputation).
• Adverse events include recognised complications, which were judged as leading to harm but being of low preventability.
Operationalisation of adverse event criteria
The review form is structured in such a way that the clinician was obliged to make specific judgments about such issues as causation before making a final decision on the presence or absence of an adverse event. The definition of an adverse event is specified in the questionnaire and referred to during each review. Many of the criteria above are essentially clarifications of the basic definition designed to overcome common problems and ensure a consistent way of working. For instance, clinicians may be reluctant to include known complications as adverse events. In fact, the definition requires that they be included, but clinicians would specify low preventability to indicate that a certain level of complications is to be expected.
In this preliminary study we primarily aimed to follow the methods of previous studies and have used the same broad definition. In the light of our experience, and of further analysis of Australian data, we believe it would now be feasible to compile a list of some of the more important adverse events before a future study and produce standardised criteria for at least a proportion of specified adverse events.
Judgments of preventability
An adverse event was considered preventable if the reviewer judged that it would not have occurred if the patient had received ordinary standards of NHS care, appropriate for the time of the study (1998). For instance omission of prophylactic antibiotics or anticoagulants specified in a department protocol. As specified above a score of 4 or above on a six point scale was required for an adverse event to be identified as preventable.
Reliability and validity of adverse event judgments
For a full discussion of sensitivity and specificity issues, and data from reliability studies, see Brennan TA, Localio AR, Laird NL. Reliability and validity of judgement concerning adverse events suffered by hospitalised patients. Med Care 1989;27:1148-58.
No of records screened No of patients with adverse events Total No of adverse events Preventable adverse events General medicine 16-29 27 2 2 2
50 3 3 2 mean = 56 years 45-64 80 4 4 2 median = 61 years 65 112 15 16 13 range = 17-97 Missing 4 0
273 24 25 19
16-29 43 2 2 1
72 6 7 3 mean = 53 years 45-64 72 14 16 7 median = 53 years 65 103 19 22 9 range = 16-94 Total 290 41 47 20
16-29 103 5 5 3
64 2 2 2 mean = 28 years 45-64 C
median = 28 years
Missing 6 0
range = 17-41
Total 173 7 7 5
16-29 36 1 1 0
52 2 2 0 mean = 58 years 45-64 63 7 7 0 median = 60.5 years 65 127 28 30 13 range = 18-102 Total 278 38 40 13
16-29 209 10 10 6
238 13 14 7 mean = 51 years 45-64 215 25 27 9 median = 50 years 65+ 342 62 68 35 range = 16-102 Missing 10 0
1014 110 119 57
No of cases Mean (range) length of stay (days) % of women Age (years) Median (mean) Range Adverse event General medicine 24 17 (1-46) 50 68.5 (63) 24-97 General surgery 41 22 (2-193) 49 62 (60) 18-90 Obstetrics 7 6 (2-11) 100 27 (27) 20-34 Orthopaedics 38 23 (2-73) 68 77.5 (74) 24-102 All specialties 110 20 (1-193) 59 68.5 (63) 18-102 No adverse event General medicine 249 11 (1-149) 44 61 (56) 17-97 General surgery 249 8 (2-113) 53 51 (52) 16-94 Obstetrics 166 4 (1-34) 100 28 (28) 17-41 Orthopaedics 240 11 (2-124) 57 56 (56) 18-98 All specialties 904 9 (1-149) 60 47.5 (50) 16-98
- This Week In The BMJ Published: 03 March 2001; BMJ 322 doi:10.1136/bmj.322.7285.0/e
- Editor's Choice Published: 03 March 2001; BMJ 322 doi:10.1136/bmj.322.7285.0/a
- Editor's Choice Published: 03 March 2001; BMJ 322 doi:10.1136/bmj.322.7285.0
- Editorial Published: 03 March 2001; BMJ 322 doi:10.1136/bmj.322.7285.501
- PRESS Published: 03 March 2001; BMJ 322 doi:10.1136/bmj.322.7285.562
- WEBSITE OF THE WEEK Published: 03 March 2001; BMJ 322 doi:10.1136/bmj.322.7285.562/a
- PRESS Published: 03 March 2001; BMJ 322 doi:10.1136/bmj.322.7285.563
- Soundings Published: 03 March 2001; BMJ 322 doi:10.1136/bmj.322.7285.563/a
- Correction Published: 09 June 2001; BMJ 322 doi:
- Analysis Published: 16 November 2009; BMJ 339 doi:10.1136/bmj.b4638
- PracticeEffect of a “Lean” intervention to improve safety processes and outcomes on a surgical emergency unitPublished: 02 November 2010; BMJ 341 doi:10.1136/bmj.c5469
- Research Published: 28 February 2008; BMJ 336 doi:10.1136/bmj.39469.763218.BE
- Practice Published: 03 April 2009; BMJ 338 doi:10.1136/bmj.b1046
- ResearchPatient safety indicators for England from hospital administrative data: case-control analysis and comparison with US dataPublished: 17 October 2008; BMJ 337 doi:10.1136/bmj.a1702
- Analysis Published: 14 May 2009; BMJ 338 doi:10.1136/bmj.b1775
- Analysis Published: 13 November 2008; BMJ 337 doi:10.1136/bmj.a2426
- ResearchSensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note reviewPublished: 11 January 2007; BMJ 334 doi:10.1136/bmj.39031.507153.AE
- RESEARCHSensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note reviewPublished: 15 December 2006; BMJ doi:10.1136/bmj.39031.507153.AE
- ResearchLarge scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluationPublished: 03 February 2011; BMJ 342 doi:10.1136/bmj.d195
- ResearchPatient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospitalPublished: 13 March 2012; BMJ 344 doi:10.1136/bmj.e832
- Obituary Published: 03 December 2013; BMJ 347 doi:10.1136/bmj.f6712
- Letter Published: 03 March 2001; BMJ 322 doi:10.1136/bmj.322.7285.548
- LetterAdverse events reporting in English hospital statistics: Data relevant to patient safety should not be presented alone and out of contextPublished: 07 October 2004; BMJ 329 doi:10.1136/bmj.329.7470.857
- Letter Published: 09 June 2001; BMJ 322 doi:10.1136/bmj.322.7299.1425
- ResearchAvoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysisPublished: 14 July 2015; BMJ 351 doi:10.1136/bmj.h3239
- Careers Published: 07 April 2010; BMJ 340 doi:10.1136/bmj.c1654
- Analysis Published: 17 May 2018; BMJ 361 doi:10.1136/bmj.k2014
- Student Published: 01 March 2003; BMJ 326 doi:10.1136/sbmj.030357
- Student Published: 01 April 2006; BMJ 332 doi:10.1136/sbmj.0604135
- ResearchPrevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysisPublished: 17 July 2019; BMJ 366 doi:10.1136/bmj.l4185
- ResearchEarly warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodologyPublished: 20 May 2020; BMJ 369 doi:10.1136/bmj.m1501
- Covid-19: Delays in getting tests are keeping doctors from work, health leaders warnBMJ September 25, 2020, 370 m3755; DOI: https://doi.org/10.1136/bmj.m3755
- Managing long covid: don’t overlook olfactory dysfunctionBMJ September 25, 2020, 370 m3736; DOI: https://doi.org/10.1136/bmj.m3736
- Sixty seconds on . . . covid-19 sniffer dogsBMJ September 25, 2020, 370 m3758; DOI: https://doi.org/10.1136/bmj.m3758
- A network for elected women: five minutes with . . . Helena McKeownBMJ September 25, 2020, 370 m3756; DOI: https://doi.org/10.1136/bmj.m3756
- Priadel: Experts urge government to intervene to keep lithium product on marketBMJ September 25, 2020, 370 m3754; DOI: https://doi.org/10.1136/bmj.m3754
- Study of a multisite prospective adverse event surveillance system
- Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research
- Preventing Complications in Pregnant Women With Cardiac Disease
- Facilitators and barriers to safer care in Scottish general practice: a qualitative study of the implementation of the trigger review method using normalisation process theory
- Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review
- Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis
- Understanding safety differently: developing a model of resilience in the use of intravenous insulin infusions in hospital in-patients--a feasibility study protocol
- Improving safety and reducing error in endoscopy: simulation training in human factors
- Protocol for a mixed-methods exploratory investigation of care following intensive care discharge: the REFLECT study
- National hospital mortality surveillance system: a descriptive analysis
- The systems approach at the sharp end
- What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study
- An analogy between socioeconomic deprivation level and loss of health from adverse effects of medical treatment in England
- Non-technical skills and gastrointestinal endoscopy: a review of the literature
- Changing how we think about healthcare improvement
- Two-epoch cross-sectional case record review protocol comparing quality of care of hospital emergency admissions at weekends versus weekdays
- Early warning scores for detecting deterioration in adult hospital patients: a systematic review protocol
- An easy, prompt and reproducible methodology to manage an unexpected increase of incident reports in surgery theatres
- Comparison of two methods to estimate adverse events in the IBEAS Study (Ibero-American study of adverse events): cross-sectional versus retrospective cohort design
- Patients' reports of adverse events: a data linkage study of Australian adults aged 45 years and over
- Systematic review of economic analyses in patient safety: a protocol designed to measure development in the scope and quality of evidence
- Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement
- Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands
- Understanding the epidemiology of avoidable significant harm in primary care: protocol for a retrospective cross-sectional study
- Quality gaps identified through mortality review
- The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals--a retrospective record review study
- Taking an organisational approach to quality improvement
- Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review
- Learning from excellence in healthcare: a new approach to incident reporting
- Pilot study on identification of incidents in healthcare transitions and concordance between medical records and patient interview data
- How safe is primary care? A systematic review
- Tip of the iceberg: patient safety incidents in primary care
- The safety of emergency medicine
- Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human
- Monitoring adverse events in Norwegian hospitals from 2010 to 2013
- Understanding Decision Making in Critical Care
- Expanding the scope of Critical Care Rapid Response Teams: a feasible approach to identify adverse events. A prospective observational cohort
- High risk of adverse events in hospitalised hip fracture patients of 65 years and older: results of a retrospective record review study
- How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time
- Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric?
- Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis
- Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a retrospective patient record review study
- Morbidity and Mortality Revisited: Applying a New Quality Improvement Paradigm in Oncology
- Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward
- Using information to deliver safer care: a mixed-methods study exploring general practitioners information needs in North West London primary care
- How do emergency physicians make discharge decisions?
- Experience feedback committee in emergency medicine: a tool for security management
- The WHO surgical safety checklist: survey of patients' views
- Implementation of an endoscopy safety checklist
- Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital: prospective cohort study
- Graham Neale
- Assessing adverse events among home care clients in three Canadian provinces using chart review
- Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus group interviews with team members
- An introduction to quality improvement in paediatrics and child health
- Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork: A Scientific Statement From the American Heart Association
- Surgical technology and operating-room safety failures: a systematic review of quantitative studies
- Toward the modelling of safety violations in healthcare systems
- Adverse events recorded in English primary care: observational study using the General Practice Research Database
- 'Bad apples': time to redefine as a type of systems problem?
- The digital patient
- Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review study
- Trends in adverse events over time: why are we not improving?