Authors' objectives: Despite global activity over the past 15 years to improve patient safety, the measurement of adverse events (AEs) remains challenging. The two-stage retrospective review methodology was used to quantify harm across NHS Wales. In total, 4536 inpatient episodes were screened for AEs by research nurses. Records that were highly suggestive of AEs were further assessed by physicians. NHS-led teams undertook GTT reviews on the same case notes.

Authors' recommendations: The extent of harm detected across NHS Wales using both the two-stage retrospective review process and the new Harm2 tool conforms to the findings in the literature, but this is the first longitudinal study using these methods. With training and using a structured review process, non-physician reviewers can undertake case note review efficiently and effectively, and the rates of AEs and of the preventability and the breakdown of problems in care conform to those reported in studies in which physicians undertake these classifications. Whether the patient died or was discharged alive significantly influences the rate and composition of AEs. The Harm2 tool performed with moderate reliability in the determination of AEs.

Project Status: Completed

Year Published: 2017

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/hsdr05090/#/abstract

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk

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