Article Text

PDF
Medical record review of deaths, unexpected intensive care unit admissions, and clinician referrals: detection of adverse events and insight into the system
  1. K L Dunn1,
  2. P Reddy2,
  3. A Moulden3,
  4. G Bowes1
  1. 1Department of Paediatrics, University of Melbourne, Australia
  2. 2Department of Psychology, University of Melbourne, Australia
  3. 3Royal Children’s Hospital, Melbourne, Australia
  1. Correspondence to:
    Dr K Dunn
    Department of Paediatrics, Royal Children’s Hospital, Flemington Rd, Melbourne, Victoria 3052, Australia; karen.dunn{at}rch.org.au

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.

  • CQS, Clinical Quality and Safety Unit
  • ICU, intensive care unit
  • PSC, Patient Safety Committee
  • patient safety
  • medical record
  • quality assurance
  • risk management
  • adverse event

Statistics from Altmetric.com

Footnotes

  • Published Online First 25 October 2005

  • Funding: Karen Dunn is supported by an NHMRC scholarship

  • Competing interests: none

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.