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
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.
Published Online First 25 October 2005
Funding: Karen Dunn is supported by an NHMRC scholarship
Competing interests: none