Journal Article

Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.

Olsen S; Neale G; Schwab K; Psaila B; Patel T; Chapman EJ; Vincent C.

All hospitals are required to have an incident reporting system, but the voluntary nature of such systems means that some errors may go unreported. This prospective cohort study compared the rate of errors detected by incident reporting, pharmacy surveillance, and medical record review by clinicians. Most adverse events were detected by record review, not by incident reporting; pharmacy surveillance revealed several adverse drug events (ADEs) that were not detected by the other methods. The failure of incident reporting systems to detect ADEs has been previously reported. A previous commentary discusses the different strategies available for error detection and the strengths and weaknesses of each approach.