Case record review of adverse events: a new approach
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TLDR
The existing clinical review form (RF2) used in previous retrospective case record review studies is redesigned in order to clarify the review process and provide a more powerful analysis of adverse events; and then to ask clinicians to pilot and evaluate the new modular reviewform (MRF2).Abstract:
Objectives: To redesign the existing clinical review form (RF2) used in previous retrospective case record review studies in order to clarify the review process and provide a more powerful analysis of adverse events; and then to ask clinicians to pilot and evaluate the new modular review form (MRF2). The review form is divided into five sections, each with a defined purpose, providing a modular structure.
Design: Design and testing of the MRF2 on a sample of medical and nursing records, and evaluation of the reviewers' responses regarding the new review form.
Setting: Hospital based teams from eight countries.
Results: The modular review form was reported to be comprehensive, well structured, and clear. Most of the reviewers agreed with the positive statements regarding the review form. Overall, the modular structure was thought to be helpful. Several modifications have been made to the final version to take account of criticisms and suggestions.
Conclusions: The full potential of case record review has yet to be explored. The benefits of this review form include a modular format which enables reviewers or project leaders to select the focus of their review based on resources and the purpose of the review, and to identify contributory factors which indicate areas for improvement and prevention. The training of reviewers is of vital importance for record review. Record review remains one of the primary methods for assessing the incidence of adverse events and the new format is suitable for both prospective and retrospective review.read more
Citations
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Journal ArticleDOI
Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events
J.M. Aranaz-Andrés,Carlos Aibar-Remón,J Vitaller-Murillo,Pedro Ruiz-López,R. Limón-Ramírez,E. Terol-García +5 more
TL;DR: The incidence of patients with AE related to medical assistance in Spanish hospitals was relevant and similar to those found in the studies from Canada and New Zealand that had been conducted with comparable methodology, indicating the need for AEs to be considered a public health priority in Europe.
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Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place
TL;DR: It is suggested that incident reporting does not provide an adequate assessment of clinical adverse events and that this method needs to be supplemented with other more systematic forms of data collection.
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Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation
Amirta Benning,Maisoon Ghaleb,Anu K. Suokas,Mary Dixon-Woods,Jeremy Dawson,Nick Barber,Bryony Dean Franklin,Alan Girling,Karla Hemming,Martin Carmalt,Gavin Rudge,Thirumalai Naicker,Ugochi Nwulu,Sopna Choudhury,Richard J. Lilford +14 more
TL;DR: The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate and there was no additional effect of SPI 1 on other targeted issues nor on other measures of generic organisational strengthening.
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Prevalence of adverse events in the hospitals of five Latin American countries: results of the ‘Iberoamerican study of adverse events’ (IBEAS)
J.M. Aranaz-Andrés,C Aibar-Remón,R Limón-Ramírez,A. Amarilla,F. R. Restrepo,O. Urroz,O. Sarabia,L V García-Corcuera,E. Terol-García,Y. Agra-Varela,J. Gonseth-García,David W. Bates,Itziar Larizgoitia,Ibeas team +13 more
TL;DR: The high rate of prevalent AE found suggests that PS may represent an important public-health issue in the participating hospitals, and may already be useful to inspire new PS-improvement policies in those settings.
Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project
Gordon D. Schiff,Seijeoung Kim,Richard Abrams,Karen Cosby,Bruce L. Lambert,Arthur S. Elstein,Scott Hasler,Nela Krosnjar,Richard Odwazny,Mary F. Wisniewski,Robert A. McNutt +10 more
TL;DR: It is known that diagnosis errors are common and underemphasized, but they are also challenging to detect and dissect, and it is often difficult even to agree whether or not a diagnosis error has occurred.
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