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

Research output: Contribution to journal(Systematic) Review article peer-review

11 Citations (Web of Science)

Abstract

Objective

To assess the reproducibility of adverse event evaluation by a medical record review committee.

Design

Cross-sectional reanalysis of medical records.

Intervention

Reviewers 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.

Results

The 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.

Conclusion

We 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.

Original languageEnglish
Article number0208087
Number of pages11
JournalPLOS ONE
Volume13
Issue number11
DOIs
Publication statusPublished - 29 Nov 2018

Keywords

  • GLOBAL TRIGGER TOOL
  • PATIENT SAFETY
  • HOSPITALS
  • RELIABILITY
  • CARE
  • HARM
  • AGREEMENT
  • QUALITY
  • DEATHS
  • RATES

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