Study of the scale, nature and causes of adverse events and methods to identify them

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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. Design Two stage retrospective review of patients' case notes and analysis of data submitted to the routine incident reporting system on the same patients. Setting A large NHS hospital in England. Population 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). Main outcome measures 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. Conclusion 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