Assessing Reliability of Medical Record Reviews for the Detection of Hospital Adverse Events

옥민수; 이진용; 조민우; 김선하; 이상일

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자료유형: 학술저널

저자정보: 옥민수 이진용 조민우 김선하 이상일

저널정보: 대한예방의학회 예방의학회지 예방의학회지 제48권 제5호

발행연도: 2015.1

수록면: 239 - 248 (10page)

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연구주제

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연구배경

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연구방법

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연구결과

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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.

#Adverse event #Patient safety #Intra-rater reliability #Inter-rater reliability #Medical record review

참고문헌 (21)

참고문헌 신청

World Health Organization / The research cycle: measuring harm

Thomas EJ / 2003 / Measuring errors and adverse events in health care / J Gen Intern Med 18(1):61~67

World Health Organization / 2010 / Assessing and tackling patient harm: a methodological guide for data-poor hospitals / World Health Organization :35~36

Brennan TA / 1991 / Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I / N Engl J Med 324(6):370~376

Rivard PE / 2008 / Using patient safety indicators to estimate the impact of potential adverse events on outcomes / Med Care Res Rev 65(1):67~87

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Ock Minsu

소속기관 Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.Department of Preventive Medicine, University of Ulsan College of Medicine