Literature DB >> 16249267

Medical record review of deaths, unexpected intensive care unit admissions, and clinician referrals: detection of adverse events and insight into the system.

K L Dunn1, P Reddy, A Moulden, G Bowes.   

Abstract

AIMS AND METHODS: To determine whether a programme of continuous medical record review of deaths, unexpected intensive care unit (ICU) admissions, and admissions referred by medical and nursing staff for specific review, would provide a range of adverse events from which to gain insight into the healthcare system of a large paediatric referral hospital. A quality assurance programme was commenced in 1996.
RESULTS: Over a six year period there were 103 255 admissions; 1612 (1.6%) records were reviewed, from which 325 adverse events were detected. Events were associated with operations, procedures and anaesthesia (56.5%), diagnosis and therapy (24%), drug and fluid management (12.6%), and system issues (7%). Medical records were reviewed from 23 of the 28 clinical units. Review of the records and analysis of the adverse events triggered many system changes.
CONCLUSIONS: The findings suggest that continuous medical record review may be a valuable method for the detection of adverse events and identifying system issues in children's hospitals.

Entities:  

Mesh:

Year:  2005        PMID: 16249267      PMCID: PMC2082690          DOI: 10.1136/adc.2005.074179

Source DB:  PubMed          Journal:  Arch Dis Child        ISSN: 0003-9888            Impact factor:   3.791


  15 in total

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2.  Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer.

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3.  Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results.

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4.  Hospital-reported medical errors in children.

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Journal:  Pediatrics       Date:  2003-03       Impact factor: 7.124

5.  Pediatric patient safety in hospitals: a national picture in 2000.

Authors:  Marlene R Miller; Chunliu Zhan
Journal:  Pediatrics       Date:  2004-06       Impact factor: 7.124

6.  Analysis of clinical incidents: a window on the system not a search for root causes.

Authors:  C A Vincent
Journal:  Qual Saf Health Care       Date:  2004-08

7.  Using focus groups to understand physicians' and nurses' perspectives on error reporting in hospitals.

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Journal:  Jt Comm J Qual Saf       Date:  2004-09

8.  Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.

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9.  Computerized physician order entry and medication errors in a pediatric critical care unit.

Authors:  Amy L Potts; Frederick E Barr; David F Gregory; Lorianne Wright; Neal R Patel
Journal:  Pediatrics       Date:  2004-01       Impact factor: 7.124

10.  Incidence of medical error and adverse outcomes on a pediatric general surgery service.

Authors:  Monja L Proctor; Jennifer Pastore; Justin T Gerstle; Jacob C Langer
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  5 in total

1.  Adverse Drug Reactions in Children--International Surveillance and Evaluation (ADVISE): a multicentre cohort study.

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Journal:  Drug Saf       Date:  2012-06-01       Impact factor: 5.606

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Authors:  Annemie Vlayen; Kristel Marquet; Ward Schrooten; Arthur Vleugels; Johan Hellings; Elke De Troy; Frank Weekers; Neree Claes
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3.  Real-time registration of adverse events in Dutch hospitalized children in general pediatric units: first experiences.

Authors:  Cynthia van der Starre; Monique van Dijk; Dick Tibboel
Journal:  Eur J Pediatr       Date:  2011-10-22       Impact factor: 3.183

4.  The ability of triggers to retrospectively predict potentially preventable adverse events in a sample of deceased patients.

Authors:  Dorthe O Klein; Roger J M W Rennenberg; Richard P Koopmans; Martin H Prins
Journal:  Prev Med Rep       Date:  2017-11-03

5.  One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals.

Authors:  Kristel Marquet; Neree Claes; Elke De Troy; Gaby Kox; Martijn Droogmans; Ward Schrooten; Frank Weekers; Annemie Vlayen; Marjan Vandersteen; Arthur Vleugels
Journal:  Crit Care Med       Date:  2015-05       Impact factor: 7.598

  5 in total

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