Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.
BACKGROUND
Over the past five years, in most hospitals in England and Wales, incident reporting has become well established but it remains unclear how well reports match clinical adverse events. International epidemiological studies of adverse events are based on retrospective, multi-hospital case record review. In this paper the authors describe the use of incident reporting, pharmacist surveillance and local real-time record review for the recognition of clinical risks associated with hospital inpatient care.


METHODS
Data on adverse events were collected prospectively on 288 patients discharged from adult acute medical and surgical units in an NHS district general hospital using incident reports, active surveillance of prescription charts by pharmacists and record review at time of discharge.


RESULTS
Record review detected 26 adverse events (AEs) and 40 potential adverse events (PAEs) occurring during the index admission. In contrast, in the same patient group, incident reporting detected 11 PAEs and no AEs. Pharmacy surveillance found 10 medication errors all of which were PAEs. There was little overlap in the nature of events detected by the three methods.


CONCLUSIONS
The findings suggest that incident reporting does not provide an adequate assessment of clinical adverse events and that this method needs to be supplemented with other more systematic forms of data collection. Structured record review, carried out by clinicians, provides an important component of an integrated approach to identifying risk in the context of developing a safety and quality improvement programme.
Olsen
Sisse
S
Clinical Safety Research Unit, Department of Bio-surgery and Technology, Imperial College, St Mary's Hospital, London, UK. s.olsen@imperial.ac.uk
Neale
Graham
G
Schwab
Kat
K
Psaila
Beth
B
Patel
Tejal
T
Chapman
E Jane
EJ
Vincent
Charles
C
D016907:Adverse Drug Reaction Reporting Systems / Q000706:statistics & numerical data*; D003625:Data Collection; D005260:Female; D019538:Health Care Surveys; D006767:Hospitals, District; D006769:Hospitals, General; D006801:Humans; D008297:Male; D008499:Medical Records; D008505:Medical Staff, Hospital; D008508:Medication Errors / Q000706:statistics & numerical data; D010564:Personnel, Hospital; D011446:Prospective Studies; D018570:Risk Assessment; D012308:Risk Management / Q000379:methods*; D013222:State Medicine; D013997:Time Factors; D017749:Total Quality Management; D006113:United Kingdom