scholarly journals Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS

BMJ Open ◽  
2016 ◽  
Vol 6 (11) ◽  
pp. e012259 ◽  
Author(s):  
Matthew Hansen ◽  
Garth Meckler ◽  
William Lambert ◽  
Caitlin Dickinson ◽  
Kathryn Dickinson ◽  
...  
Keyword(s):  
Patient Safety ◽  
Airway Management ◽  
Medical Record ◽  
Medical Record Review ◽  
Record Review

scholarly journals Validity and reliability of a medical record review method identifying transitional patient safety incidents in merged primary and secondary care patients’ records

BMJ Open ◽  
2018 ◽  
Vol 8 (8) ◽  
pp. e018576 ◽  
Author(s):  
Marije A van Melle ◽  
Dorien L M Zwart ◽  
Judith M Poldervaart ◽  
Otto Jan Verkerk ◽  
Maaike Langelaan ◽  
...  
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Medical Records ◽  
Secondary Care ◽  
Information Transfer ◽  
Safety Issue ◽  
Medical Center ◽  
Medical Record Review ◽  
Measurement Tool ◽  
Record Review

ObjectiveInadequate information transfer during transitions in healthcare is a major patient safety issue. Aim of this study was to pilot a review of medical records to identify transitional safety incidents (TSIs) for use in a large intervention study and assess its reliability and validity.DesignA retrospective medical record review study.Settings and participantsCombined primary and secondary care medical records of 301 patients who had visited their general practitioner and the University Medical Center Utrecht, the Netherlands, in 2013 were randomly selected. Six trained reviewers assessed these medical records for presence of TSIs.OutcomesTo assess inter-rater reliability, 10% of medical records were independently reviewed twice. To assess validity, the identified TSIs were compared with a reference standard of three objectively identifiable TSIs.ResultsThe reviewers identified TSIs in 52 (17.3%) of all transitional medical records. Variation between reviewers was high (range: 3–28 per 50 medical records). Positive agreement for finding a TSI between reviewers was 0%, negative agreement 80% and the Cohen’s kappa −0.15. The reviewers identified 43 (22%) of 194 objectively identifiable TSIs.ConclusionThe reliability of our measurement tool for identifying TSIs in transitional medical record performed by clinicians was low. Although the TSIs that were identified by clinicians were valid, they missed 80% of them. Restructuring the record review procedure is necessary.

scholarly journals Limited external reproducibility restricts the use of medical record review for benchmarking

2019 ◽  
Vol 8 (2) ◽  
pp. e000564
Author(s):  
Dorthe O Klein ◽  
Roger Rennenberg ◽  
Rijk Gans ◽  
Roelien Enting ◽  
Richard Koopmans ◽  
...  
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
The Netherlands ◽  
Medical Record ◽  
Medical Records ◽  
Medical Record Review ◽  
Quality And Safety ◽  
Internal Review ◽  
Record Review ◽  
Kappa Agreement

BackgroundMedical record review (MRR) is used to assess the quality and safety in hospitals. It is increasingly used to compare institutions. Therefore, the external reproducibility should be high. In the current study, we evaluated this external reproducibility for the assessment of an adverse event (AE) in a sample of records from two university medical centres in the Netherlands, using the same review method.MethodsFrom both hospitals, 40 medical records were randomly chosen from patient files of deceased patients that had been evaluated in the preceding years by the internal review committees. After reviewing by the external committees, we assessed the overall and kappa agreement by comparing the results of both review rounds (once by the own internal committee and once by the external committee). This was calculated for the presence of an AE, preventability and contribution to death.ResultsKappa for the presence of AEs was moderate (k=0.47). For preventability, the agreement was fair (k=0.39) and poor for contribution to death (k=−0.109).ConclusionWe still believe that MRR is suitable for the detection of general issues concerning patient safety. However, based on the outcomes of this study, we would advise to be careful when using MRR for benchmarking.

scholarly journals Validation of ICD-10-CM codes for injuries complicating pregnancy, childbirth and the puerperium: a medical record review

2021 ◽  
Vol 27 (Suppl 1) ◽  
pp. i9-i12
Author(s):  
Anna Hansen ◽  
Dana Quesinberry ◽  
Peter Akpunonu ◽  
Julia Martin ◽  
Svetla Slavova
Keyword(s):  
Emergency Department ◽  
Medical Record ◽  
International Classification Of Diseases ◽  
Medical Record Review ◽  
Full Sample ◽  
Emergency Department Data ◽  
Classification Of Diseases ◽  
Icd 10 ◽  
Record Review

IntroductionThe purpose of this study was to estimate the positive predictive value (PPV) of International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes for injury, poisoning, physical or sexual assault complicating pregnancy, childbirth and the puerperium (PCP) to capture injury encounters within both hospital and emergency department claims data.MethodsA medical record review was conducted on a sample (n=157) of inpatient and emergency department claims from one Kentucky healthcare system from 2015 to 2017, with any diagnosis in the ICD-10-CM range O9A.2-O9A.4. Study clinicians reviewed medical records for the sampled cases and used an abstraction form to collect information on documented presence of injury and PCP complications. The study estimated the PPVs and the 95% CIs of O9A.2-O9A.4 codes for (1) capturing injuries and (2) capturing injuries complicating PCP.ResultsThe estimated PPV for the codes O9A.2-O9A.4 to identify injury in the full sample was 79.6% (95% CI 73.3% to 85.9%) and the PPV for capturing injuries complicating PCP was 72.0% (95% CI 65.0% to 79.0%). The estimated PPV for an inpatient principal diagnosis O9A.2-O9A.4 to capture injuries was 90.7% (95% CI 82.0% to 99.4%) and the PPV for capturing injuries complicating PCP was 88.4% (95% CI 78.4% to 98.4%). The estimated PPV for any mention of O9A.2-O9A.4 in emergency department data to capture injuries was 95.2% (95% CI 90.6% to 99.9%) and the PPV for capturing injuries complicating PCP was 81.0% (95% CI 72.4% to 89.5%).DiscussionThe O9A.2-O9A.4 codes captured high percentage true injury cases among pregnant and puerperal women.

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