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

Abstract

ObjectiveTo assess the reproducibility of adverse event evaluation by a medical record review committee.DesignCross-sectional reanalysis of medical records.InterventionReviewers re-examined fifty medical records of deceased patients regarding the presence of adverse events, their potential preventability and their possible contribution to death. Also we investigated the root causes of the preventable AEs. Differences between the first and second assessment were calculated.ResultsThe Kappa on the presence of an adverse event was 0.64 and 0.32 for the potential preventability. The intrarater agreement showed a Kappa of 0.61 on the adverse event presence and 0.64 for the potential preventability. Interrater agreement showed a Kappa of 0.66 for the adverse event presence and 0.03 for the potential preventability.ConclusionWe found a fair reproducibility for the detection of adverse events, but a poor reproducibility for the potential preventability. Possibly this was caused by lack of a definition for the preventability of adverse events. We think giving feedback to professionals using the results of medical record review remains valuable, but an improvement of its reproducibility is essential. To our opinion an international consensus on what exactly constitutes preventability of adverse events and agreement on a definition is necessary. This would result in more comparable studies in this field and could then be more informative on the ideal procedure to avoid certain potentially preventable adverse events in the future.

Incident Reporting System in an Italian University Hospital: A New Tool for Improving Patient Safety

“…In a systemic and systematic perspective of a right clinical risk management, different methods, tools and actions are expected to revel risk sources, to provide useful evidences about the incident of adverse events, and therefore to reach a reduction and containment of the same [ 5 , 6 ]. These processes take advantage of proactive precise tools that hospitals experiment and use with different degrees of awareness, the main of which are safety briefings, focus groups, analysis and review of medical records, screening, observations, patient safety walkaround and global trigger tool [ 7 ].…”

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

“…During the previous years, both committees used the same review procedure. Previous research showed the results of this internal MRR to be acceptably reliable 12…”

Helsetjenesteassosiert infeksjon som årsak til død i sykehus

“…Man må vaere varsom i vurderingen av hvor mange dødsfall som kan forebygges, da dette er vanskelig å fastslå (26)(27)(28). Kompleksiteten i moderne sykehusbehandling er et poeng, og man har funnet betydelig variasjon i undersøkernes vurdering (26,27). I en nyere publikasjon fra Canada blir det sagt at virkelig forebyggbare dødsfall er sjeldne (29).…”