Limited adverse event screening: using medical record review to reduce hospital adverse patient events

1996 ◽  
Vol 165 (3) ◽  
pp. 176-176
Author(s):  
Pauline Branley ◽  
Noel E Cranswick ◽  
Anne‐Marie Pellizzer ◽  
M Kent Garrett ◽  
Graeme M Vernon ◽  
...  
Keyword(s):  
Adverse Event ◽  
Medical Record ◽  
Medical Record Review ◽  
Record Review

scholarly journals Adverse event detection by medical record review is reproducible, but the assessment of their preventability is not

PLoS ONE ◽  
2018 ◽  
Vol 13 (11) ◽  
pp. e0208087 ◽  
Author(s):  
Dorthe O. Klein ◽  
Roger J. M. W. Rennenberg ◽  
Richard P. Koopmans ◽  
Martin H. Prins
Keyword(s):  
Adverse Event ◽  
Medical Record ◽  
Event Detection ◽  
Medical Record Review ◽  
Record Review

The Reliability of Medical Record Review for Estimating Adverse Event Rates

2002 ◽  
Vol 136 (11) ◽  
pp. 812 ◽  
Author(s):  
Eric J. Thomas ◽  
Stuart R. Lipsitz ◽  
David M. Studdert ◽  
Troyen A. Brennan
Keyword(s):  
Adverse Event ◽  
Medical Record ◽  
Medical Record Review ◽  
Event Rates ◽  
Record Review

scholarly journals Variation between hospitals and reviewers in detection of adverse events identified through medical record review in Korea

2020 ◽  
Vol 32 (8) ◽  
pp. 495-501
Author(s):  
Sukyeong Kim ◽  
Ho Gyun Shin ◽  
A E Jeong Jo ◽  
Ari Min ◽  
Minsu Ock ◽  
...  
Keyword(s):  
Adverse Event ◽  
Adverse Events ◽  
Medical Record ◽  
Medical Records ◽  
Third Party ◽  
Medical Record Review ◽  
Screening Criteria ◽  
Discharged Patients ◽  
Record Review ◽  
Inpatient Units

Abstract Objectives This study utilized the method of medical record review to determine characteristics of adverse events that occurred in the inpatient units of hospitals in Korea as well as the variations in adverse events between institutions. Design A two-stage retrospective medical record review was conducted. The first stage was a nurse review, where two nurses reviewed medical records of discharged patients to determine if screening criteria had been met. In the second stage, two physicians independently reviewed medical records of patients identified in the first stage, to determine whether an adverse event had occurred. Setting Inpatient units of six hospitals. Participants Medical records of 2 596 patients randomly selected were reviewed in the first stage review. Intervention(s) N/A. Main Outcome Measure(s) Adverse events. Results A total of 277 patients (10.7%) were confirmed to have had one or more adverse event(s), and a total of 336 adverse events were identified. Physician reviewers agreed about whether an adverse event had occurred for 141 patients (5.4%). The incidence rate of adverse events was at least 1.3% and a maximum of 19.4% for each hospital. Most preventability scores were less than four points (non-preventable), and there were large variations between reviewers and institutions. Conclusions Given the level of variation in the identified adverse events, further studies that include more medical institutions in their investigations are needed, and a third-party committee should be involved to address the reliability issues regarding the occurrence and characteristics of the adverse events.

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.

Sign in / Sign up

Export Citation Format

Share Document