• M Ricci, A P Goldman, M R de Leval, G A Cohen, F Devaney, and J Carthey.
• Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK. mricci@med.miami.edu
• Arch. Dis. Child. 2004 Sep 1;89(9):856-9.

AimsTo evaluate the pitfalls of incident reporting in a complex medical environment.MethodsRetrospective review of 211 incident reports in a paediatric cardiac intensive care unit (CICU). Two adverse event reporting databases were compared: database A (DA), the hospital's official reporting system, is non-anonymous and reports are predominantly made by nurses; database B (DB) is anonymous and reports are submitted by a CICU consultant who collects data from daily ward rounds. Both databases classify adverse events into incident type (drug errors, ventilation, cannulae/indwelling lines, chest drains, blood transfusion, equipment, operational) and severity (0 = no, 1 = minor, 2 = major, 3 = life threatening consequences).ResultsBetween 1 April 1998 and 31 July 2001 there were 211 adverse events involving 178 patients (11.87%), among 1500 patients admitted to CICU. A total of 112 incidents were reported in DA, 143 in DB, and 44 in both. In isolation, both databases gave an unrepresentative picture of the true frequency and severity of adverse events. Under-reporting was especially notable for less severe events (grade 0, or near misses)ConclusionIncident reporting in the medical field is highly variable, and is heavily influenced by profession of the reporters as well as anonymity. When adverse event reporting is based predominantly on the observations of a single professional group, the data are grossly inaccurate.

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