Author(s): Shaw R, Drever F, Hughes H, Osborn S, Williams S
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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.
This article was published in Qual Saf Health Care
and referenced in Emergency Medicine: Open Access