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 Diagnosis and treatment of patients with antiphospholipid syndrome: a mixed-method evaluation of care in The Netherlands

2020 ◽  
Vol 4 (2) ◽  
Author(s):  
Mirthe J Klein Haneveld ◽  
Caro H C Lemmen ◽  
Tammo E Brunekreef ◽  
Marc Bijl ◽  
A J Gerard Jansen ◽  
...  
Keyword(s):  
The Netherlands ◽  
Focus Groups ◽  
Medical Record ◽  
Medical Records ◽  
Quantitative Methods ◽  
Medical Record Review ◽  
Anticoagulant Treatment ◽  
Medical Specialists ◽  
Record Review ◽  
Fragmentation Of Care

Abstract Objectives The aims were to gain insight into the care provided to patients with APS in The Netherlands and to identify areas for improvement from the perspective of both patients and medical specialists. Methods APS care was evaluated using qualitative and quantitative methods. Perspectives on APS care were explored using semi-structured interviews with medical specialists, patient focus groups and a cross-sectional, online patient survey. In order to assess current practice, medical records were reviewed retrospectively to collect data on clinical and laboratory manifestations and pharmacological treatment in six Dutch hospitals. Results Fourteen medical specialists were interviewed, 14 patients participated in the focus groups and 79 patients completed the survey. Medical records of 237 patients were reviewed. Medical record review showed that only one-third of patients were diagnosed with APS within 3 months after entering specialist care. The diagnostic approach and management varied between centres and specialists. Almost 10% of all patients and 7% of triple-positive patients with thrombotic APS were not receiving any anticoagulant treatment at the time of medical record review. Correspondingly, poor recognition and fragmentation of care were reported as the main problems by medical specialists. Additionally, patients reported the lack of accessible, reliable patient education, psychosocial support and trust in physicians as important points for improvement. Conclusion Delayed diagnosis, variability in management strategies and fragmentation of care were important limitations of APS care identified in this study. A remarkable 10% of patients did not receive any anticoagulant treatment.

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 ReCAP: Detection of Potentially Avoidable Harm in Oncology From Patient Medical Records

2016 ◽  
Vol 12 (2) ◽  
pp. 178-179 ◽  
Author(s):  
Allison Lipitz-Snyderman ◽  
Saul N. Weingart ◽  
Christopher Anderson ◽  
Andrew S. Epstein ◽  
Aileen Killen ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Medical Record ◽  
Cancer Care ◽  
Medical Records ◽  
Screening Tool ◽  
Real Life ◽  
Risk Groups ◽  
Medical Record Review ◽  
Efficient Detection ◽  
Record Review

QUESTION ASKED: Although medical record–based measurement of adverse events (AEs) associated with cancer care is desirable, condition-specific triggers in oncology care are needed. We sought to develop a screening tool to facilitate efficient detection of AEs across settings of cancer care via medical record review. We hope to use this tool to understand the frequency, spectrum, and preventability of AEs with the goal of helping improve the quality and safety of cancer care. SUMMARY ANSWER: We developed a cancer-specific screening tool to help identify candidate preventable AEs that occur during cancer care from patients’ medical records. Our oncology screening tool consists of 76 triggers—readily identifiable findings to screen for possible AEs that occur during cancer care ( Table 1 ). METHODS: We sought to develop a screening tool to facilitate the detection of AEs across settings of cancer care via medical record review. We obtained structured and unstructured input from clinical experts to develop our tool, using a modified Delphi process. BIAS, CONFOUNDING FACTOR(S), DRAWBACKS: Our oncology tool requires further evaluation in order to understand its usefulness for population-based assessments of AEs in oncology and quality improvement. REAL-LIFE IMPLICATIONS: Information obtained from structured record reviews using an oncology trigger tool could help to prioritize quality improvement activities, identify high-risk groups, and generate cancer-focused quality measures. Ultimately, the goals of this work are to prevent AEs and allow timely, automated identification of these events so that clinicians can intervene promptly to improve patient outcomes. [Table: see text]

Abstract P270: Automating Processes to Expedite Medical Record Review in Research

2011 ◽  
Vol 4 (suppl_1) ◽  
Author(s):  
K M Reeder ◽  
Edward Ellerbeck ◽  
Marilyn Werkowitch ◽  
N. Nazir ◽  
B. Waltrip ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Emergency Room ◽  
Medical Record ◽  
Medical Records ◽  
Chart Review ◽  
Medical Record Review ◽  
Automated System ◽  
Emergency Room Visits ◽  
Automated Method ◽  
Record Review

Problem. Heart failure (HF) clinical trials often use medical record review data to determine HF related hospital events, such as emergency room visits and readmissions. However, reviewing medical records for each hospital event can be daunting. The purpose of this project was to expedite medical record review processes using an automated method for identifying potential HF related hospital events. Methods. A stepwise procedure was developed for obtaining electronic information of all consented HF clinical trial participants' hospital events. First, an electronic list of all study participants was generated from a study data base and electronically sent to the Medical Records department each month. Next, a list of all emergency room visits and hospitalizations, including admission and discharge dates, discharge disposition, and diagnosis and procedure codes was electronically generated by the Medical Records department. A trained cardiovascular research nurse reviewed the abstracted coding and billing data for each hospital event and identified specific codes potentially related to HF. Last, hospital events identified as meeting specific criteria were included in the medical record review. Results. Using the automated system, a total of 294 hospital events for 125 subjects were obtained from the Medical Records department during the initial 2 years of the clinical trial. Of these, 85 (29%) hospital events were identified as needing to undergo chart review. Thirty-three (39%) of the 85 charts that underwent blinded review were identified as being HF related hospital events. Conclusions. Automating procedures for obtaining hospital event information expedited both the systematic data review and chart review processes. In this study, combined use of automated processes for obtaining hospital event data and nurse review reduced the number of charts requiring blinded review by nearly 60%.

Accuracy of Healthcare Worker Recall and Medical Record Review for Identifying Infectious Exposures to Hospitalized Patients

2006 ◽  
Vol 27 (7) ◽  
pp. 722-728 ◽  
Author(s):  
M. Aquino ◽  
J. M. Raboud ◽  
A. McGeer ◽  
K. Green ◽  
R. Chow ◽  
...  
Keyword(s):  
Medical Record ◽  
Healthcare Worker ◽  
Medical Records ◽  
Medical Record Review ◽  
Contact Tracing ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Memory Aids ◽  
Record Review

Objective.To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting.Design.Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of possible exposure) and the availability of patients' medical records for use as memory aids on the accuracy of HCW recall.Setting.A 10-bed medical-surgical intensive care unit at Mount Sinai Hospital in Toronto, Ontario.Patients.Thirty-six HCWs observed caring for 16 patients, for a total of 55 healthcare worker shifts.Results.Recall accuracy was better among HCWs who were provided with patient medical records as memory aids (P<.01). However, HCWs tended to overestimate exposures when they used patient medical records as memory aids. For 6 of 26 procedures or care activities, this tendency to overestimate was statistically significant (P<.05). Most HCWs with true exposures were identified by means of this technique, despite the overestimations. Documentation of the activities of the 4 service assistants could not be found in any of the patients' medical records. Similarly, the interactions between 6 (19%) of 32 other patient–HCW pairs were not recorded in patients' medical records.Conclusions.Data collected from follow-up interviews with HCWs in which they are provided with patient medical records as memory aids should be adequate for contact tracing and for determining exposure histories. Neither follow-up interviews nor medical record review alone provide sufficient data for these purposes.

scholarly journals Tinjauan Pelaksanaan Review Rekam Medis dalam Rangka Persiapan Akreditasi Rumah Sakit Berdasarkan Standar Akreditasi SNARS-1 di RSUD Sultan Thaha Saifuddin Kabupaten Tebo Provinsi Jambi

2021 ◽  
Vol 9 (1) ◽  
pp. 47-56
Author(s):  
Novi Mulyani Putri ◽  
Witri Zuama Qomarania ◽  
Hosizah Hosizah
Keyword(s):  
Field Study ◽  
Medical Record ◽  
Medical Records ◽  
Medical Record Review ◽  
Accreditation Standard ◽  
Standard Methods ◽  
Period 2 ◽  
Review Form ◽  
Record Review

AbstractSultan Thaha Saifuddin Hospital is heading towards the implementation of SNARS-1. The first phase of accreditation in 2016 uses the 2012 version with only four services (SKP, HPK, KPS, PPI) so that there is no medical record review assessment as in the MIRM 13.4 SNARS-1 assessment element. Currently, Sultan Thaha Saifuddin Hospital must adjust the medical record review with the MIRM standard on SNARS-1. Field Study Practices at the Sultan Thaha Saifuddin Hospital, Tebo Jambi Regency on April 1, 2019 to April 20, 2019 with the aim of knowing the implementation of medical record reviews based on the SNARS-1 accreditation standard. Methods of data collection are carried out by observation and interviews using observation sheets and interview guides. The results of the field study practice are: there is a team responsible for reviewing medical records called the medical record committee; there is an SPO regarding medical record review; review of medical records using an open, closed, and recapitulation review form; There was an increase in the quality of medical records based on the results of reviews between period 1 and period 2, namely from 89.65% to 96.8% on timeliness, an increase from 95.4% to 97.6% in legibility, and an increase from 97, 6% to 99.2% on completeness of medical records. The implementation of reviewing medical records at Sultan Thaha Saifuddin Hospital is in accordance with the applicable SPO. The implementation of the review is also in accordance with the SNARS-1 assessment elements.Keyword: medical record, completness, Accreditation Assessment SNARS-1                                                                AbstrakRSUD Sultan Thaha Saifuddin sedang menuju implementasi SNARS-1. Akreditasi tahap pertama tahun 2016 menggunakan versi 2012 baru sebatas empat pelayanan (SKP, HPK, KPS, PPI) sehingga belum ada penilaian review rekam medis seperti pada elemen penilaian MIRM 13.4 SNARS-1. Saat ini, RSUD Sultan Thaha Saifuddin harus menyesuaikan review rekam medis dengan standar MIRM pada SNARS-1. Praktik Belajar Lapangan dilakukan di RSUD Sultan Thaha Saifuddin Kabupaten Tebo Jambi pada tanggal 01 April 2019 sampai 20 April 2019 dengan tujuan untuk mengetahui pelaksanaan review rekam medis berdasarkan standar akreditasi SNARS-1. Metode pengumpulan data dilakukan dengan observasi dan wawancara menggunakan lembar observasi dan panduan wawancara. Hasil praktik belajar lapangan yaitu: terdapat tim yang bertanggung jawab pada review rekam medis disebut panitia rekam medis; terdapat SPO tentang review rekam medis; review rekam medis menggunakan form review terbuka, tertutup, serta rekapitulasi; terdapat kenaikan kualitas rekam medis berdasarkan hasil review antara periode 1 dan periode 2 yaitu dari 89,65% menjadi 96,8% pada ketepatan waktu, terjadi kenaikan  dari 95,4% menjadi 97,6% pada keterbacaan, serta terjadi kenaikan dari 97,6% menjadi 99,2% pada kelengkapan rekam medis. Pelaksanaan review rekam medis di RSUD Sultan Thaha Saifuddin telah sesuai dengan SPO yang berlaku. Pelaksanaan review juga telah sesuai dengan elemen penilaian SNARS-1.Kata Kunci: rekam medis, kelengkapan, akreditasi SNARS-1

scholarly journals Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment

2016 ◽  
Vol 22 (4) ◽  
pp. 1055-1062
Author(s):  
Elizabeth Rebello ◽  
Spencer Kee ◽  
Alicia Kowalski ◽  
Nusrat Harun ◽  
Michele Guindani ◽  
...  
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Safety Issue ◽  
Electronic Record ◽  
Time Out ◽  
Patient Safety Issue ◽  
Anesthesia Time ◽  
Over Time

Opening and charting in the incorrect patient electronic record presents a patient safety issue. The authors investigated the prevalence of reported errors and whether efforts utilizing the anesthesia time-out and barcoding have decreased the incidence of errors in opening and charting in the patient electronic medical record in the perioperative environment. The authors queried the database for all surgeries and procedures requiring anesthesia from January 2009 to September 2012. Of the 115,760 records of anesthesia procedures identified, there were 57 instances of incorrect record opening and charting during the study period. A decreasing trend was observed for all sites combined ( p < 0.0001) and at the off-site locations ( p = 0.0032). All locations and the off-site locations demonstrated a statistically significant decreasing pattern of errors over time. Barcoding and the anesthesia time-out may play an important role in decreasing errors in incorrect patient record opening in the perioperative environment.

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