Adverse events and near miss reporting in the NHS.
OBJECTIVE
To conduct a multicentre study on adverse event and near miss reporting in the NHS and to explore the feasibility of creating a national system for collecting these data.


METHODS
Prospective voluntary reporting by staff with anonymised transfer of data was used by a national system to collect data from 18 NHS trusts.


METHODS
Staff from 12 acute trusts, three mental health trusts, two ambulance trusts, and one primary care trust.


METHODS
Number of incidents, date and time of incident, patient age and sex, clinical speciality, location, outcome, risk rating, type and description of incident.


RESULTS
A total of 28 998 incidents were reported including 11 766 (41%) slips, trips and falls, 2514 (9%) medication management incidents, 2429 (8%) resource issues, and 2164 (7%) treatment issues. 138 catastrophic and 260 major adverse outcomes were reported. Slips, trips and falls (n = 11 766) were the most common type of incident.


CONCLUSIONS
Voluntary reporting by staff when linked to a multicentre data collecting system can yield information on a large number of incidents. This provides support for the principle of creating a national IT system to collect and analyse incident data.
Shaw
R
R
National Patient Safety Agency, London, UK.
Drever
F
F
Hughes
H
H
Osborn
S
S
Williams
S
S
D000058:Accidental Falls / Q000517:prevention & control / Q000706:statistics & numerical data; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D005260:Female; D006077:Government Agencies; D006748:Hospital Departments; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D008875:Middle Aged; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D012308:Risk Management; D017751:Safety Management; D013222:State Medicine; D006113:United Kingdom