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In this new volume of Quality in Health Care we have decided to modify the structure of the journal scan. Each issue will still include a scan of the core medical journals—BMJ, JAMA, Lancet, and New England Journal of Medicine—but, in addition, we will invite a health professional to do a scan of the published literature based on a particular theme. The theme of the scan for the articles reviewed by Ross Scrivener in this issue is risk management.

Risk management

Bibliographic search strategy used

Medline (PubMed) was searched using the terms “medication errors” and “risk management” together. The following articles were selected from 41 articles that appeared during October 1998 to October 1999 indexed under these terms.

Stanhope N, Crowley-Murphy M, Vincent C, et al. An evaluation of adverse event reporting . J Eval Clin Pract 1999 Feb; 5 :5–12.

Abstract adapted from the original article.


To determine the reliability of adverse event reporting in two teaching hospital obstetric units by (a) establishing what proportion of adverse incidents were not reported by staff and (b) determining whether a maternity risk manager can increase the reliability of adverse incident reporting by searching through various types of documentation.


Two obstetric units serving similar populations and with comparable numbers of deliveries. Both units had established risk management programmes led by a maternity risk manager.


A retrospective review of the notes relating to 250 consecutive deliveries in each of the two obstetric units. Notes were screened for the presence of adverse incidents defined by lists of incidents to be recorded in accordance with unit protocols.


A total of 196 adverse incidents were identified from the 500 deliveries. Staff reported 23% of these and the risk managers identified a further 22%. The remaining 55% of incidents were identified only by …

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