The effectiveness of incident reporting

With the encouragement of the CNST and the implementation of An Organisation with a Memory, adverse incident reporting is being introduced throughout the United Kingdom , yet there are currently no studies in the UK assessing its value and reliability. To examine the reliability of adverse incident reporting systems, a retrospective review of the mother and baby medical notes from a series of 500 deliveries in two London obstetric units was carried out. Medical notes were screened by a senior research midwife for the presence of adverse incidents defined by clinical indicator lists of incidents to be reported in accordance with unit protocols.

Staff reported 23% of 196 reportable incidents and the dedicated maternity risk managers identified a further 22%. The remaining 55% of incidents were identified only by retrospective case note review and were not known to the risk manager. Staff reported about half of the serious incidents (48%), but comparatively few of the moderately serious (24%) or minor ones (15%). Incident reporting systems may produce much potentially valuable information, but seriously underestimate the true level of reportable incidents. Where one risk manager covers an entire Trust, rather than a single unit, reporting rates are likely to be very much lower than in the present study.

Stanhope N, Crowley-Murphy M, Vincent C, O'Connor AM, Taylor-Adams SE. An evaluation of adverse incident reporting. Journal of Evaluation in Clinical Practice 1999; 5(1):5-12.

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