Hospitals are missing patient safety problems

Reported by Susan Aldridge, PhD, medical journalist

Patient safety incidents are being under-reported in hospitals because of weaknesses in the reporting system.
If a patient is involved in a so-called safety incident in hospital, there ought to be some way of reporting and following it up. Such incidents can include accidents or drugs given at the wrong dose. They are relatively common, but may not always result in lasting harm. A study in the British National Health Service now reveals that the reporting system for patient safety is at fault.

Researchers looked at data from the routine reporting system, comparing it with patient case notes. In a random sample of 1006 admissions, there were 324 patient safety incidents. Case note review revealed 93 per cent of these, while the reporting system identified only 17 per cent. Of the incidents, 42 per cent resulted in patient harm. All of these were in the case notes, but only five per cent were picked up by the reporting system.

The 21 incidents that were missed by case notes were minor, but the 130 incidents missed by the reporting system led to patient harm. Clearly the reporting system is in need of a major overhaul because it is missing the scale and severity of patient safety incidents.

Source
BMJ Online First 14th December 2006