Hospitals miss most patient safety incidents

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

Hospital reporting systems may significantly under-report patient safety incidents, particularly those resulting in harm, warns a study published on bmj.com today.

The authors suggest that the current system, which relies on voluntary reporting, may not be sufficient if the NHS is to gather accurate information on the extent of harm resulting from patient safety incidents.

Patient safety incidents are common in hospitals, and many of them lead to patient harm or extra cost. In 2003, the National Patient Safety Agency developed a national reporting and learning system to help the NHS identify, analyse, and learn from patient safety incidents.

All NHS hospitals now have routine incident reporting systems as part of their risk management programme.

To test the performance of these systems, researchers compared data from the routine reporting system with a review of case notes for the same patients in a large NHS hospital in England.

From a random sample of 1006 admissions, 324 patient safety incidents were identified. Case note review identified 303 (93%) of incidents, while the reporting system identified 54 (17%).

Of these 324 incidents, 136 (42%) resulted in patient harm. All of these were detected by the case note review but only 6 (5%) were detected by the reporting system.

The 21 incidents missed by case note review were minor, whereas the 130 incidents missed by the reporting system led to patient harm.

The routine reporting system in this large hospital missed most patient safety incidents that were identified by case note review and detected only 5% of those incidents that resulted in patient harm, say the authors. This suggests that the routine reporting systems considerably under-reports the scale and severity of patient safety incidents.

A recent report by the House of Commons Committee of Public Accounts was critical of the adequacy of the national reporting and learning system. This study provides empirical evidence that the data sent to the system may be biased.

More research is needed to help develop a reporting system that is capable of providing an accurate picture of the type, nature, and severity of incidents and at reasonable cost, they write. Healthcare organisations should consider routinely using structured case note review on samples of medical records as part of quality improvement, they conclude.

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Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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