Medical record review of deaths, unexpected intensive care unit admissions, and clinician referrals: detection of adverse events and insight into the system. Issue 2 (25th October 2005)

• Record Type: Journal Article
• Authors: Dunn, K L; Reddy, P; Moulden, A; Bowes, G
• Is Part Of: Archives of disease in childhood. Volume 91:Issue 2(2006)
• Page Start: 169
• Page End: 172
• Publication Date: 2005-10-25
• Subjects: CQS, Clinical Quality and Safety Unit -- ICU, intensive care unit -- PSC, Patient Safety Committee; patient safety -- medical record -- quality assurance -- risk management -- adverse event; Children -- Diseases -- Periodicals; Infants -- Diseases -- Periodicals; 618.920005
• DOI: 10.1136/adc.2005.074179
• Languages: English
• ISSNs: 0003-9888

Abstract

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.