Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.
OBJECTIVE
To evaluate the performance of a routine incident reporting system in identifying patient safety incidents.


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


METHODS
A large NHS hospital in England.


METHODS
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).


METHODS
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.


CONCLUSIONS
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.
Sari
Ali Baba-Akbari
AB
Department of Health Sciences, University of York, York YO10 5DD.
Sheldon
Trevor A
TA
Cracknell
Alison
A
Turnbull
Alastair
A
D004739:England; D006760:Hospitalization; D006761:Hospitals / Q000592:standards*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D008499:Medical Records; D015397:Program Evaluation; D012189:Retrospective Studies; D012308:Risk Management / Q000458:organization & administration / Q000592:standards*; D017751:Safety Management / Q000458:organization & administration / Q000592:standards; D012680:Sensitivity and Specificity