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Medical record review of deaths, unexpected intensive care unit admissions, and clinician referrals: detection of adverse events and insight into the system


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

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