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An evaluation of adverse incident reporting
N Stanhope1, M Crowley-Murphy, C Vincent
1Department of Psychology (Torrington Place), University College London, UK.
Journal of Evaluation in Clinical Practice
|September 1, 1999
Summary
Adverse incident reporting systems significantly underestimate actual events, with staff reporting only 23% and risk managers identifying 22%. Over half of incidents were missed, highlighting major gaps in patient safety monitoring.
Area of Science:
- Obstetrics and Gynecology
- Patient Safety
- Healthcare Management
Background:
- Adverse incident reporting systems are crucial for patient safety.
- Reliability of these systems in identifying all adverse events is often questioned.
- Understanding reporting gaps is key to improving healthcare quality.
Purpose of the Study:
- To evaluate the reliability of adverse incident-reporting systems in obstetric units.
- To quantify the underestimation of adverse incidents by current reporting protocols.
- To identify specific areas for improvement in incident detection and reporting.
Main Methods:
- Retrospective review of 500 mother and baby case notes from two London obstetric units.
- Screening for adverse incidents based on unit-specific reporting protocols.
- Assessing reported incidents versus those identified through case note review.
Main Results:
- 196 adverse incidents were identified; only 23% were reported by staff.
- Risk managers identified an additional 22%; 55% were identified only by retrospective review.
- Serious incidents were reported more often (48%) than moderate (24%) or minor (15%) ones; drug errors were significantly underreported.
Conclusions:
- Current incident-reporting systems substantially underestimate the true incidence of adverse events.
- Improved clarity on reportable incidents, continuing staff education, and designated reporting roles are necessary.
- Systematic underreporting poses a significant risk to patient safety and quality improvement efforts.