Reporting systems miss many patient safety incidents
Routine incident reporting systems considerably under-report the scale
and severity of patient safety incidents, according to research published
online in BMJ First last week (15 December 2006).
Incidents identified through a two-stage retrospective review of patients’ case
notes (carried out by trained nurses and doctors) were compared with
data submitted to the routine incident reporting system for a large NHS
trust in England. Data collected covered 1,006 admissions under eight
specialties.
Between January and May 2004, 324 patient safety incidents were identified
in 230 of the 1,006 admissions (22.9 per cent). Case note review identified
303 of the incidents (94 per cent) and the reporting system identified
54 incidents (17 per cent).
Of the 1,006 admissions, 110 (10.9 per cent) had at least one patient
safety incident resulting in harm. All of these incidents were detected
by case note review but only six were detected by the reporting system.
All 21 of the patient safety incidents missed by case review were minor,
whereas 130 incidents missed by the reporting system resulted in patient
harm. There were 71 drug problems missed by the incident reporting system.
“If the NHS is to gather accurate information on serious injuries
and deaths resulting from patient safety incidents … then relying
on voluntary reporting may not be sufficient,” say the researchers.
They suggest that early themes emerging from National Reporting and Learning
System data may be useful but estimates of the type and severity of the
incidents may be biased. “Health care organisations should consider
routinely using structured case note review on samples of medical records
as part of quality improvement,” they say. |
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