Article Text

PDF

Adverse events and near miss reporting in the NHS
  1. R Shaw1,2,
  2. F Drever1,
  3. H Hughes1,
  4. S Osborn1,
  5. S Williams1
  1. 1National Patient Safety Agency, London, UK
  2. 2Hammersmith Hospitals NHS Trust, London, UK
  1. Correspondence to:
 Professor R Shaw

Abstract

Objectives: 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.

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

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

Main outcomes measured: 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.

  • patient safety
  • incident reporting
  • adverse events

Statistics from Altmetric.com

Footnotes

  • Conflict of interest: none.

    These data have been made public in an appendix to the NPSA Business Plan 2002/3.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.