Medical record review of deaths, unexpected intensive care unit admissions, and clinician referrals: detection of adverse events and insight into the system.
OBJECTIVE
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.
Dunn
K L
KL
Department of Paediatrics, University of Melbourne, Australia. karen.dunn@rch.org.au
Reddy
P
P
Moulden
A
A
Bowes
G
G
D002648:Child; D017052:Hospital Mortality; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D007362:Intensive Care Units; D008485:Medical Audit / Q000379:methods; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008499:Medical Records; D010343:Patient Admission / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care; D012017:Referral and Consultation; D012308:Risk Management / Q000379:methods; D014739:Victoria