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Original Article
- Assessing Reliability of Medical Record Reviews for the Detection of Hospital Adverse Events
- Minsu Ock, Sang-il Lee, Min-Woo Jo, Jin Yong Lee, Seon-Ha Kim
- J Prev Med Public Health. 2015;48(5):239-248. Published online September 11, 2015
- DOI: https://doi.org/10.3961/jpmph.14.049
- 9,290 View
- 112 Download
- 12 Crossref
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Abstract
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Supplementary Material - Objectives
The purpose of this study was to assess the inter-rater reliability and intra-rater reliability of medical record review for the detection of hospital adverse events.
Methods
We conducted two stages retrospective medical records review of a random sample of 96 patients from one acute-care general hospital. The first stage was an explicit patient record review by two nurses to detect the presence of 41 screening criteria (SC). The second stage was an implicit structured review by two physicians to identify the occurrence of adverse events from the positive cases on the SC. The inter-rater reliability of two nurses and that of two physicians were assessed. The intra-rater reliability was also evaluated by using test-retest method at approximately two weeks later.
Results
In 84.2% of the patient medical records, the nurses agreed as to the necessity for the second stage review (kappa, 0.68; 95% confidence interval [CI], 0.54 to 0.83). In 93.0% of the patient medical records screened by nurses, the physicians agreed about the absence or presence of adverse events (kappa, 0.71; 95% CI, 0.44 to 0.97). When assessing intra-rater reliability, the kappa indices of two nurses were 0.54 (95% CI, 0.31 to 0.77) and 0.67 (95% CI, 0.47 to 0.87), whereas those of two physicians were 0.87 (95% CI, 0.62 to 1.00) and 0.37 (95% CI, -0.16 to 0.89).
Conclusions
In this study, the medical record review for detecting adverse events showed intermediate to good level of inter-rater and intra-rater reliability. Well organized training program for reviewers and clearly defining SC are required to get more reliable results in the hospital adverse event study. -
Summary
Citations
Citations to this article as recorded by
- The Korea National Patient Safety Incidents Inquiry Survey: Feasibility of Medical Record Review for Detecting Adverse Events in Regional Public Hospitals
Min Ji Kim, Hee Jung Seo, Hong Mo Koo, Minsu Ock, Jee-In Hwang, Sang-Il Lee
Journal of Patient Safety.2022; 18(5): 389. CrossRef - The Korea National Patient Safety Incidents Inquiry Survey: Characteristics of Adverse Events Identified Through Medical Records Review in Regional Public Hospitals
Min Ji Kim, Hee Jung Seo, Hong Mo Koo, Minsu Ock, Jee-In Hwang, Sang-Il Lee
Journal of Patient Safety.2022; 18(5): 382. CrossRef - Feasibility of Capturing Adverse Events From Insurance Claims Data Using International Classification of Diseases, Tenth Revision, Codes Coupled to Present on Admission Indicators
Juyoung Kim, Eun Young Choi, Won Lee, Hae Mi Oh, Jeehee Pyo, Minsu Ock, So Yoon Kim, Sang-il Lee
Journal of Patient Safety.2022; 18(5): 404. CrossRef - Quality of end-of-life communication in 2 high-risk ICU cohorts: a retrospective cohort study
Tammy L. Pham, Allan Garland
CMAJ Open.2021; 9(2): E570. CrossRef - A Systematic Review of Methods for Medical Record Analysis to Detect Adverse Events in Hospitalized Patients
Dorthe O. Klein, Roger J.M.W. Rennenberg, Richard P. Koopmans, Martin H. Prins
Journal of Patient Safety.2021; 17(8): e1234. CrossRef - Patient Safety Incidents Reported by the General Public in Korea: A Cross-Sectional Study
Minsu Ock, Min-Woo Jo, Eun Young Choi, Sang-Il Lee
Journal of Patient Safety.2020; 16(2): e90. CrossRef - Perceptions of Hospital Health Information Managers Regarding Present on Admission Indicators in Korea: A Qualitative Study
Jee-Hee Pyo, Eun-Young Choi, Hae-Mi Oh, Won Lee, Ju-Young Kim, Min-Su Ock, So-Yoon Kim, Sang-Il Lee
Quality Improvement in Health Care.2020; 26(1): 23. CrossRef - Variation between hospitals and reviewers in detection of adverse events identified through medical record review in Korea
Sukyeong Kim, Ho Gyun Shin, A E Jeong Jo, Ari Min, Minsu Ock, Jee-In Hwang, Youngjin Jeong, Moon Sung Park, Jong Bouk Lee, Tae I K Chang, Eunhyang Song, Heungseon Kim, Sang-Il Lee
International Journal for Quality in Health Care.2020; 32(8): 495. CrossRef - The Harvard medical practice study trigger system performance in deceased patients
Dorthe O. Klein, Roger J. M. W. Rennenberg, Richard P. Koopmans, Martin H. Prins
BMC Health Services Research.2019;[Epub] CrossRef - Optimising Hepatitis C care in an urban Aboriginal and Torres Strait Islander primary health care clinic
Prabha Lakhan, Deborah Askew, Noel Hayman, Leigh‐anne Pokino, Cheryl Sendall, Paul J. Clark
Australian and New Zealand Journal of Public Health.2019; 43(3): 228. CrossRef - Patient and hospital characteristics that influence incidence of adverse events in acute public hospitals in Portugal: a retrospective cohort study
Paulo Sousa, António Sousa Uva, Florentino Serranheira, Mafalda Sousa Uva, Carla Nunes
International Journal for Quality in Health Care.2018; 30(2): 132. CrossRef - Interpregnancy weight change and adverse pregnancy outcomes: a systematic review and meta-analysis
Eugene Oteng-Ntim, Sofia Mononen, Olga Sawicki, Paul T Seed, Debra Bick, Lucilla Poston
BMJ Open.2018; 8(6): e018778. CrossRef
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