Journal of Human Hypertension (2001) 15, 587–591
 2001 Nature Publishing Group All rights reserved 0950-9240/01 $15.00
ORIGINAL ARTICLE
The extent and implications of
sphygmomanometer calibration error in
primary care
A Rouse and T Marshall
Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham B15
2TT, UK
Aim: The sphygmomanometer is an essential piece of
diagnostic equipment, used in many routine consul-
tations in primary care. Its accuracy depends on correct
maintenance and calibration. This study was designed
to: (1) assess the maintenance and calibration of sphyg-
momanometers in use in primary care; (2) assess the
clinical, ethical, legal and public health implications of
our findings.
Method: A researcher assessed the accuracy of mercury
and aneroid sphygmomanometers in use in 231 English
general practices. He also made enquires about
arrangements for the maintenance and calibration of
sphygmomanometers. We conducted a small telephone
survey in general practices across the country to deter-
mine maintenance and calibration arrangements across
the country. We carried out a modelling exercise to
explore the clinical, ethical and public health impli-
cations of our findings.
Keywords: blood pressure determination/is [instrumentation]; family practice; medical audit; England; calibration
Introduction
Accurate estimation of blood pressure requires the
use of an accurate sphygmomanometer, which has
been serviced and calibrated. A British Standard
(BS2743) exists for the assessment of sphygmoman-
ometers and this has been endorsed by the British
Hypertension Society.1
Previous surveys have found that sphygmoman-
ometers used in primary care are rarely if ever recali-
brated. Hussain found that 23% of practitioners had
never (⬎6 years) had their sphygmomanometers
calibrated.2 Maskrey et al3 in North Yorkshire in
1997 found that 40% of practices could not recall
when sphygmomanometers were last tested. In two-
thirds of practices, no testing had taken place for at
least a year.3 They comment that these low levels
Correspondence: A Rouse, Department of Public Health and Epi-
demiology, University of Birmingham, Edgbaston, Birmingham
B15 2TT, UK. E-mail: A.M.Rouse얀bham.ac.uk
Received 5 February 2001; revised and accepted 28 April 2001
www.nature.com/jhh
Results: Of 1462 sphygmomanometers, 9.2% gave read-
ings were more than 5 mm Hg inaccurate. No practice
had arrangements for maintenance and calibration of
sphygmomanometers. Nationally, one of 54 practices
had an arrangement for maintenance and calibration.
True hypertension is very uncommon in women under
35, a blood pressure which is measured as high is much
more likely to be caused by calibration error than by
hypertension.
Conclusion: It is rare for sphygmomanometers used in
primary care to be maintained and calibrated. Because
of this women under 35 are at risk of misclassification
and inappropriate treatment. This has ethical and public
health implications. Clinicians using equipment which
has not been maintained and calibrated may be medi-
cally negligent.
Journal of Human Hypertension (2001) 15, 587–591
are perhaps not surprising since sphygmoman-
ometer ‘servicing is an unusual component of hyper-
tension audit programmes and is not recorded at all
as a key criteria in a recent British literature
review’.4 Nor are these findings confined to Britain.
A survey of 125 sphygmomanometers used in a pre-
hospital setting in the USA, found over one-third
were more than 4 mm Hg inaccurate and one in 10
more than 8 mm Hg inaccurate.5 In a separate survey
of sphygmomanometers owned by members of the
public, one in 10 were more than 6 mm Hg inaccur-
ate.6
To investigate this problem we conducted a sur-
vey of sphygmomanometers used in general prac-
tices in Birmingham Health Authority. We tested the
accuracy of sphygmomanometers and asked primary
care teams about arrangements for their calibration
and maintenance. We also conducted a small survey
of practices in England and Wales to test the general-
isability of our findings. Finally we modelled the
implications of the findings for clinical practice. We
report our results and discuss their wider impli-
cations.
 Sphygmomanometer calibration error in primary care
A Rouse and T Marshall

588
Subjects and methods
Survey of general practices
Between March and July 1999 a researcher trained
in the calibration of sphygmomanometers visited all
of the 231 practices serving Birmingham Health
Authority. He offered a free assessment of the accu-
racy of all aneroid and mercury sphygmoman-
ometers in use by any member of the practice, using
methods which complied with British Standard
(BS2743).7 A sphygmomanometer, which was tested
and certified according to British Standard
(BS2743), was obtained from a manufacturer. The
rubber air tubing of this sphygmomanometer and a
the sphygmomanometer being tested were connec-
ted with a Y connector. The air pressure of the com-
bined system was increased to 250 mm Hg. Pressure
was then slowly reduced to 20 mm Hg. Any differ-
ence in pressure between the certified and tested
sphygmomanometers was noted. The measurement
error was recorded for each sphygmomanometer. As
part of the protocol, enquiries were also made using
a checklist, about arrangements for the calibration
and maintenance of sphygmomanometers.
Telephone survey
To establish whether similar findings with respect
to arrangements for calibration and maintenance
applied to the rest of England and Wales, we carried
out a small telephone survey. We obtained a list of
randomly ordered practice telephone numbers, con-
tacted practices in this order, aiming to obtain
results from 50. We secured results from 54 prac-
tices. In each we spoke with either a doctor, practice
manager or nurse and asked what arrangements
were in place to ensure that sphygmomanometers
were regularly serviced and calibrated.
manometers—such as those identified in our sur-
vey—were used. For each age–sex group we calcu-
lated the probability of a normotensive being
misclassified as hypertensive. We also calculated
the positive predictive values of blood pressure
which is measured as hypertensive.
Results
Survey of general practices
A total of 217 (94%) practices—serving a combined
population of 1 million—accepted the offer of cali-
bration. In all, 1582 sphygmomanometers were
identified: 120 electronic, 949 mercury and 513
aneroid. We were unable to assess the calibration
of electronic sphygmomanometers. The calibration
errors of the 1462 mercury and aneroid sphygmo-
manometers are shown in Table 1. Nineteen percent
gave readings which were inaccurate by more than
2 mm Hg; 9.2% gave readings which were inaccur-
ate by more than 5 mm Hg. No practice had arrange-
ments for the ongoing recalibration and mainte-
nance of sphygmomanometers. Nearly 100
sphygmomanometers were in such a poor physical
state, for instance they had air leaks or dirt in the
mercury, that the tester suggested they be with-
drawn from service. There was no relationship
between the age and accuracy of sphygmoman-
ometers, with some new devices giving inaccurate
readings.
Telephone survey
Of 54 practices contacted in the telephone survey,
only one (95% confidence interval (CI) 0.1 to 11.2%)
had a formal arrangement for servicing and cali-
bration. Thirty-four practices (95% CI 49% to 75%)
accepted servicing and calibration by drug company

Modelling exercise Table 1 Distribution of measurement errors in 1462 sphygmo-

manometers in 217 practices
British Hypertension Society guidelines classify as
hypertensive all patients whose systolic blood press- Degree of Percentage of affected
ure exceeds 160 mm Hg or diastolic blood pressure measurement errora sphygmomanometers
exceeds 100 mm Hg.8 To determine the clinical
implications of the findings of our survey, we perfor- ⭐−30 mm Hg 0.5%
med a modelling exercise based on the population −29.9 to −25 mm Hg 0.2%
−25.9 to −20 mm Hg 0.3%
of England and Wales. We obtained the distribution −19.9 to −15 mm Hg 0.8%
of systolic and diastolic blood pressures in the −14.9 to −10 mm Hg 0.5%
population from the Health Survey of England −9.9 to −5 mm Hg 3.6%
1996.9 This survey provides the most recent estimate −4.9 to −2.1 mm Hg 6.6%
−2.0 to +1.9 mm Hg 80.8%
of the prevalence of raised blood pressure in the +2 to +4.9 mm Hg 3.3%
community. For each age–sex group we calculated +5 to +9.9 mm Hg 2.0%
the prevalence of systolic and diastolic blood press- +10 to +14.9 mm Hg 0.8%
ures exceeding the British Hypertension Society cri- +15 to +19.9 mm Hg 0.1%
teria for hypertension. These are the true (gold +20 to +24.9 mm Hg 0.3%
+25 to +29.9 mm Hg 0.1%
standard) age–sex specific prevalences of high blood ⭓⫹30 mm Hg 0.1%
pressure. We then calculated the number of persons
who would meet the British Hypertension Society a
Positive numbers indicate overestimation, negative numbers
criteria for hypertension if uncalibrated sphygmo- indicate underestimation.

Journal of Human Hypertension

 Sphygmomanometer calibration error in primary care
A Rouse and T Marshall

Table 2 The prevalence of hypertension, the probability of misclassification with an uncalibrated sphygmomanometer and the positive 589
predictive values of raised blood pressuresa

Systolic blood pressure ⬎160 mm Hg Diastolic blood pressure ⬎100 mm Hg

True Misclassified Misclassified Positive True Misclassified Misclassified Positive

prevalence hypertensive normotensive predictive prevalence hypertensive normotensive predictive
% % % value % % % % value %

Men
16–24 1.0 0.2 0.0 83.6 0.0 0.1 0.0 0.0
25–34 2.0 0.2 0.0 89.3 1.0 0.2 0.1 82.2
35– 44 3.0 0.3 0.1 92.0 2.0 0.4 0.1 83.5
45–54 9.0 0.4 0.1 95.6 5.0 0.6 0.3 89.4
55–64 17.0 0.6 0.3 96.5 6.0 0.6 0.4 89.9
65–74 33.0 0.8 0.5 97.6 8.0 0.6 0.5 92.8
75+ 36.0 0.8 0.4 97.7 8.0 0.5 0.5 93.9

Women
16–24 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.0
25–34 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.0
35– 44 1.0 0.1 0.0 89.6 1.0 0.2 0.1 82.4
45–54 8.0 0.3 0.1 96.2 3.0 0.3 0.2 90.7
55–64 23.0 0.6 0.3 97.3 4.0 0.4 0.2 89.6
65–74 32.0 0.8 0.4 97.5 6.0 0.4 0.4 93.3
75+ 47.0 1.0 0.6 98.0 9.0 0.4 0.5 95.2

a
British Hypertension Society criteria: blood pressure ⬎160 mm Hg systolic or ⬎100 mm Hg diastolic.

representatives on an ad-hoc or regular basis. Nine-
teen practices (95% CI, 23% to 49%) had not ser-
viced or calibrated their sphygmomanometers for
years, nor had a servicing or calibration arrangement
ever been in place.
Modelling exercise
The results of the modelling exercise are shown in
Table 2. If blood pressure is checked with an uncali-
brated sphygmomanometer, a small number of
patients will be misclassified. In patients over 35,
this is not of great practical significance as the prob-
ability of being misclassified is small in relation to
the true prevalence of hypertension. However, true
hypertension is very infrequent under the age of 35
and is practically never encountered in young
women. A woman under 35 whose blood pressure is
measured with an uncalibrated sphygmomanometer
has a small probability of being misclassified as
hypertensive. The positive predictive value of a
blood pressure measured as ⬎160/100 mm Hg is 0%
in such a woman. Our model therefore suggests that
all young women classified as hypertensive have
been misclassified.
In men under 25, the positive predictive value of
a diastolic blood pressure measured as ⬎100 mm Hg
is 0% and 83.6% for systolic hypertension. Our
model suggests that one in every six men under 25
classified as hypertensive has been misclassified.
Discussion
Blood pressure readings taken on any individual
vary from minute to minute, hour to hour and day
to day. There are two causes of this variation: bio-
logical variation in blood pressure and measurement
error. More than 30 potential sources of measure-
ment error have been cited.10 Most are easily cat-
egorised as either relating to the patient (for
example, ‘white coat’ reaction to the physician, anx-
iety, pain, full bladder); the clinician (faulty blood
pressure measurement technique); or the instrument
(sphygmomanometer error). Hypertension is diag-
nosed after blood pressure measurements taken on
three separate occasions. This three-reading policy
reduces the probability of making an erroneous diag-
nosis of hypertension due to biological variation in
blood pressure. It may also reduce errors due to
patient factors. However, if a patient’s blood press-
ure is measured with a sphygmomanometer which
has a systematic error, the blood pressure reading
will be inaccurate whether it is repeated three or 300
times. Uncalibrated sphygmomanometer error is
therefore of great clinical importance. Since few
practices have a system which ensures that sphyg-
momanometers are accurate, it appears all patients
are at risk of this kind of measurement error.
The conclusions of our modelling exercise depend
on two facts: that the prevalence of hypertension in
young women is very low; and that only young
women whose blood pressures exceed 160 mm Hg
will be considered for treatment.
Our estimate of the prevalence of hypertension is
derived from the Health Survey for England. This
was conducted on a representative sample of the
population, with blood pressure estimated on the
basis of the mean of the second and third of three
measures taken on the same occasion.9 Guidelines
recommend clinicians estimate blood pressure on

Journal of Human Hypertension

 Sphygmomanometer calibration error in primary care
A Rouse and T Marshall
590
the basis of repeated measures on separate
occasions.8 The reported prevalence of hypertension
is lower in surveys where measurement takes place
at two or more points in time.11 The Health Survey
for England may therefore have overestimated the
true prevalence of hypertension. A recently pub-
lished survey identified 0.2% of female university
students as hypertensive and a declining prevalence
of hypertension in successive cohorts.12 This con-
firms the impression that hypertension is very
uncommon in women of this age.
Might young women who have additional risk fac-
tors but with blood pressure below the threshold of
160 mm Hg also benefit from treatment? There is no
plausible combination of risk factors which would
justify treatment of a young woman for hyperten-
sion. According to the Framingham risk equation, a
diabetic woman smoker aged 34 with a systolic
blood pressure of 159 mm Hg and a total cholesterol
to high-density lipoprotein cholesterol of 6.0 has a
5-year cardiovascular risk of 11%.13 She is therefore
below the 15% 5-year risk threshold at which the
British Hypertension Society suggests treatment
should be offered.8 One per cent of all women under
35 have systolic blood pressures 150 to 159 mm Hg,9
less than 0.1% have a total cholesterol to high-
density lipoprotein cholesterol of 6.0; only a tiny
minority are diabetic smokers.14
Practical implications of instrument calibration
Calibrating instruments is not difficult or expensive.
The police recalibrate radar guns daily, chefs cali-
brate thermometers in beakers of crushed ice, and
managers of local tyre garages calibrate wheel-
balancing instruments weekly. Organisation of a
recalibration schedule should be within the capacity
of any practice.
Clinical and ethical implications
Clinicians who use an uncalibrated sphygmoman-
ometer will classify some young women as hyper-
tensive. We have demonstrated that virtually all of
these young women will have been misclassified.
The first duty of a doctor is to do no harm: non-
maleficence. Unfortunately, since all drugs have
potential side effects and all treatments incon-
venience patients, preventive treatments in healthy
patients may break this injunction. This is ethical
when it is judged that the likelihood of the patient
benefiting from treatment exceeds the likelihood of
the treatment causing harm. That is, when a benefit-
risk threshold—such as that specified in the British
Hypertension Guidelines—is exceeded.8 There may
be specific reasons to measure a young (under 35)
woman’s blood pressure, such as pregnancy or renal
disease. However, if blood pressure estimation is
carried out with the aim of preventing cardiovascu-
lar disease the results clearly show that unselected
young women are much more likely to be misclassi-
Journal of Human Hypertension
fied than correctly identified as hypertensive. Since
a misclassified young woman is clearly below the
benefit-risk threshold: treating her would break the
injunction to do no harm. Checking her blood press-
ure with an uncalibrated instrument can only result
in harm, it therefore cannot be ethical.
Public health implications
There are about 7 million women aged from 16 to
34 in England and Wales. The great majority have
their blood pressure checked frequently: for
example following registration with a practice or
when receiving contraceptive advice. Our model
suggests that about 7000 (0.1%) are at risk of mis-
classification and inappropriate treatment as a result
of sphygmomanometer calibration error. In England
and Wales about 24 000 women under 35 are on
hypotensive treatment.15 We do not know how many
of these women are receiving treatment unnecess-
arily.
Legal implications
In a non-clinical situation a professional practitioner
has clear legal responsibilities. For example, a pro-
fessional surveyor may take a series of measure-
ments to determine whether a house shows signs of
subsidence. He may advise expensive restorative
work on the basis of his measurements. What if the
owner later finds out that the surveyor’s instruments
were not calibrated; that the relevant professional
body recommends annual recalibration; and that
because of this lack of calibration the advice is very
likely to have been inappropriate? The professional
surveyor has failed in his duty of care, he is at fault
and is liable for any costs incurred by the owner.
The clinical situation is clearly equivalent. Would
the legal interpretation be the same? To date this has
not been tested.
Conclusions
Calibration of sphygmomanometers is within the
scope of all general practices. Primary care prac-
titioners have a clinical, ethical and possibly legal
responsibility to ensure their instruments are appro-
priately serviced and maintained. As a minimum
first step, all clinicians should have a system in
place to ensure that their sphygmomanometers are
recalibrated regularly to the standard endorsed by
the British Hypertension Society. Any clinician who
does not have such a system is in place, should stop
measuring blood pressure in healthy young women.
Acknowledgements
Thanks are due to Mr Brian Pritchard for carrying
out the survey of sphygmomanometers.
Andrew Rouse obtained data on sphygmoman-
ometer calibration error, made a crude estimate of

the prevalence of misclassification error and contrib-
uted to writing the paper.
Tom Marshall developed models for estimating
the prevalence of misclassification due to uncali-
brated sphygmomanometer error and contributed to
writing the paper.
Conflicts of interest
None
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