An evaluation of adverse incident reporting

To examine the reliability of adverse incident-reporting systems we carried out a retrospective review of the mother and baby case notes from a series of 250 deliveries in each of two London obstetric units. Notes were screen ed for the presence of adverse incidents defined by lists of incidents to b e reported in accordance with unit protocols. We assessed the percentage of adverse incidents reported by staff to the maternity risk manager at each unit; the percentage of incidents detected by each risk manager, but not re ported; and the percentage of incidents identified only by retrospective ca se note review. A total of 196 adverse incidents was identified from the 50 0 deliveries. Staff reported 23% of these and the risk managers identified a further 22%. The remaining 55% of incidents were identified only by retro spective case-note review and not known to the risk manager, Staff reported about half the serious incidents (48%), but comparatively few of the moder ately serious (24%) or minor ones (15%). The risk managers identified an ad ditional 16% of serious incidents that staff did not report. Drug errors we re analysed separately; only two were known to the risk managers and a furt her 44 were found by case-note review. Incident-reporting systems may produ ce much potentially valuable information, but seriously underestimate the t rue level of reportable incidents. Where one risk manager covers an entire trust, rather than a single unit, reporting rates are likely to be very muc h lower than in the present study. Greater clarity is needed regarding the definition. of reportable incidents (including drug errors). Staff should r eceive continuing education about the purposes and aims of clinical risk ma nagement and incident reporting and consideration should be given to design ating specific members of staff with responsibility for reporting.