Research · Oct 23, 2026
Assessment and reporting of harm in clinical trials
Concept
An adverse event is any untoward occurrence during treatment, whether or not a causal relation is suspected. It occurs in both arms and is compared between them. An adverse effect is a noxious response for which a causal relation is at least a reasonable possibility. Harm is the sum of adverse effects. Severe measures intensity; serious measures medical consequence: death, life threat, initial or prolonged hospitalization, disability, congenital anomaly, or need for intervention to prevent harm.
Benefit has a prespecified outcome and a sample size calculated for it. Harm rarely does. The number of possible events is large, many are unknown at the start, and each has frequency, severity and duration.
Strengths and limits of the trial
A randomized trial has a comparable control group, allows events of interest to be defined in advance, reduces assessment bias when blinded and follows participants systematically.
There are four limits. The population is selected and lower risk; older people, patients with comorbidities and users of other drugs are often excluded. Power is low for rare events: about 3,000 participants are needed to observe one case with 95% probability if the true incidence is 1 in 1,000. Duration is short for late effects. Effects not looked for are not found: without ECGs, arrhythmia goes undetected; without HbA1c, diabetes does.
Venning reviewed 18 important adverse reactions; clinical trials played a key role in identifying 3. Among new FDA boxed warnings in 2009, 76% came from spontaneous reports.
Collection: volunteered or solicited
Open questions (“any health problems?”) capture unexpected events and tend to record the more intense ones. Structured questionnaires record more events in a standard way. In AMIS, direct questioning raised the proportion of complaints in both groups, and the aspirin-placebo difference appeared with both methods. For sensitive symptoms the gap is larger: sexual dysfunction with antidepressants was reported by 46.5% with a specific scale, against 1% to 2% by spontaneous report in fluoxetine trials.
Classification and time
MedDRA is the standard dictionary. Its roughly 20,000 preferred terms fragment a single problem: depression can be coded under 22 terms. Counts per term become small and a real difference can be diluted. Aggregating at higher levels or with standardized queries (SMQs) requires clinical judgment and should be described.
Timing matters. In AMIS, stomach pain with aspirin peaked early and then declined. In DCCT, intensive glycemic control caused early retinal worsening but reduced long-term progression of retinopathy; stopping on the early finding would have led to the opposite conclusion.
Analysis
- Standard reporting. Overall dropout and by reason, event table by group, serious events, deaths and laboratory abnormalities. Tables with a frequency threshold (for example, > 5%) omit rare events, which may be the most serious.
- Adverse events of special interest. Defined in the protocol from mechanism, animal data or drugs of the same class. They can be adjudicated by a blinded committee. Adjudication can lower counts through restrictive definitions. In RE-LY, the FDA concluded that information on group assignment was available to adjudicators in 17% of cases.
- Post hoc analyses and data mining. These generate hypotheses and should be labeled as such.
- Meta-analysis. Useful when individual trials are inconclusive, but limited by incomplete reporting and publication bias. Absence of a significant difference does not prove safety.
Reporting
Ioannidis and Lau assessed 192 trials: severity of clinical adverse effects was adequately defined in 39%, and 46% gave reasons for discontinuation due to toxicity. The CONSORT harms extension (2004) has ten recommendations, among them defining each event, describing how it was collected, giving denominators and presenting absolute risk per arm. Pitrou and colleagues, in 133 trials from 2006, found 47.4% with no information on withdrawal due to adverse events and 32.3% with restricted reporting, for example only the most common events.
A useful severity hierarchy is: permanent discontinuation, permanent dose reduction, temporary reduction, complaint without change.
Common errors when reading a paper
- Reading “no difference in adverse events” as proof of safety.
- Using “safety” in place of “harm”, which describes what was measured.
- Ignoring the low-risk population and short duration when generalizing.
- Accepting an event table with a frequency threshold without a list of serious events.
- Comparing rates across trials with different collection methods.
What to check when reading a trial
- How events were collected: open question, questionnaire, tests.
- Which events of special interest were prespecified and how they were defined.
- Denominators and absolute risk per arm, including serious events.
- Dropout for adverse events, dose reduction and discontinuation, by group.
- Duration of exposure and timing of event onset.
Related topics: absolute and relative effect, multiple comparisons, meta-analysis.
References
- Friedman LM, Furberg CD, DeMets DL, Reboussin DM, Granger CB. Fundamentals of Clinical Trials. 5th ed. Springer; 2015. Chapter 12, Assessment and Reporting of Harm.
- Aspirin Myocardial Infarction Study Research Group. A randomized, controlled trial of aspirin in persons recovered from myocardial infarction. JAMA. 1980;243(7):661-9. PMID: 6985998
- The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-86. doi: 10.1056/NEJM199309303291401
- Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139-51. doi: 10.1056/NEJMoa0905561
- Moore TJ, Singh S, Furberg CD. The FDA and new safety warnings. Arch Intern Med. 2012;172(1):78-80. doi: 10.1001/archinternmed.2011.618
- Ioannidis JP, Lau J. Completeness of safety reporting in randomized trials: an evaluation of 7 medical areas. JAMA. 2001;285(4):437-43. doi: 10.1001/jama.285.4.437
- Ioannidis JP, Evans SJ, Gøtzsche PC, et al. Better reporting of harms in randomized trials: an extension of the CONSORT statement. Ann Intern Med. 2004;141(10):781-8. doi: 10.7326/0003-4819-141-10-200411160-00009
- Pitrou I, Boutron I, Ahmad N, Ravaud P. Reporting of safety results in published reports of randomized controlled trials. Arch Intern Med. 2009;169(19):1756-61. doi: 10.1001/archinternmed.2009.306