Intended for healthcare professionals


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

BMJ 2007; 334 doi: (Published 11 January 2007) Cite this as: BMJ 2007;334:79
  1. Ali Baba-Akbari Sari, research fellow1,
  2. Trevor A Sheldon, professor of health sciences, pro-vice chancellor1,
  3. Alison Cracknell, specialist registrar2,
  4. Alastair Turnbull, consultant physician3
  1. 1Department of Health Sciences, University of York, York YO10 5DD
  2. 2Leeds General Infirmary, Leeds LS1 3EX
  3. 3York Hospital, York YO31 8HE
  1. Correspondence to: T A Sheldon tas5{at}
  • Accepted 3 November 2006


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

Design Two stage retrospective review of patients' case notes and analysis of data submitted to the routine incident reporting system on the same patients.

Setting A large NHS hospital in England.

Population 1006 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).

Main outcome measures Proportion of admissions with at least one patient safety incident; proportion and type of patient safety incidents missed by routine incident reporting and case note review methods.

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

Conclusion The routine incident reporting system may be poor at identifying patient safety incidents, particularly those resulting in harm. Structured case note review may have a useful role in surveillance of routine incident reporting and associated quality improvement programmes.


  • We thank Alan Maynard, Mike White, and Michael Porte for their support and advice. We also thank for their advice Denis Smith, Carl Thompson, Fiona Fylan, Richard Lilford, Charles Vincent, Graham Neale, Maria Woloshynowych, Martin Bland, Jeremy Miles, Ian Woods, Ann McEvoy, Donald Richardson, Glen Miller, Caroline Mosely, Dawn Taylor, Mary Nannary, and Sally Grabham. We are also grateful to clinical and administrative staff of the host hospital for their support.

  • Contributors: AB-AS designed and managed the project, wrote the research proposal, collected and analysed data, and wrote the final paper. TAS supervised the project; commented on the protocol, data collection, and analysis; was responsible for the quality control; and assisted on the paper. AC and AT piloted the instruments and process, assisted with stage two case note review, provided advice, and commented on the paper. Celia Grant, Eileen Richardson, William Gray, Yvonne Dobson, and Lorraine Wright screened the medical records and collected data in stage one and discussed the findings. AB-AS is the guarantor.

  • Funding: AB-AS was supported by a scholarship from the Iranian Ministry of Health and now works at the School of Public Health, Teheran University of Medical Sciences. All the researchers are independent from the Iranian Ministry of Health.

  • Competing interest: None declared.

  • Ethical approval: Hospital research ethics committee (reference number 04/Q1108/7).

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