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Aspects of retrospective record review: - A matter of patient safety
Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Health Care is of great value but despite increased efforts to improve patient safety, many patients still suffer harm caused by healthcare, and even more patients have encountered incidents that could have caused harm. Adverse events can be detected by using retrospective record review. The Harvard Medical Practice Study and the Global Trigger Tool are such methods. Retrospective record review has shown better coverage than the commonly used clinical incident reporting system to identify patient safety information.

Aims: The general aim of the thesis was to evaluate, compare and expand retrospective record review methods for clinical use in health care. The specific aims were;

  • To evaluate the agreement in judgments of adverse events between well-trained Global Trigger Tool teams from different hospitals.
  • To describe strengths and weaknesses, from team members perspectives of working with the Global Trigger Tool method of retrospective record review to identify adverse events causing patient harm.
  • To evaluate the feasibility and capability of two common retrospective record review methods, the "Harvard Medical Practice Study" method and the "Global Trigger Tool" in detecting adverse events in adult orthopedic inpatients.
  • To evaluate retrospective record review for the detection and characterization of no-harm incidents and compare findings with conventional incident reporting systems.

Methods: A random sample of fifty patient records was reviewed by a team from each of five hospitals according to the Global Trigger Tool method (I). The teams were interviewed in focus groups concerning their experiences of the Global Trigger Tool method (II). In papers III and IV, a random sample of 350 orthopaedic admissions was examined. The outcomes from the Harvard Medical Practice Study and the Global Trigger Tool methods were compared (III). In paper IV the Harvard Medical Practice Study method was also used for identifying no harm incidents.

Results: The number of identified adverse events differed between the teams, corresponding to a level of adverse events ranging from 27.2 to 99.7 per 1000 hospital days. Differences were also found in the assessment of level of harm and judgment of preventability. Four of the teams made similar assessments while the fifth identified three times as many adverse events compared to the other teams (I).

Eight categories with their strengths and weaknesses emerged from the focus group interviews. The team members were constant in their generally positive experiences of the Global Trigger Tool method, even if the teams over time altered the application of the method (II).

With the Harvard Medical Practice Study and the Global Trigger Tool methods combined, 160 adverse events were identified in 105 (30%) of the 350 records. The Harvard Medical Practice Study method identified 155 (97%) adverse events in 104 of 350 records compared with 137 (86%) adverse events in 98 records using the Global Trigger Tool method. The adverse events causing the greatest differences were the ones causing minimal or moderate impairment (III).

In paper IV, results showed that 118 no harm incidents were detected in 91 (26%) of the 350 patient records. Ninety-four of the 118 (80%) no-harm incidents were classified as preventable. Sixteen no-harm incidents were identified by the five conventional incident reporting systems. Of these, ten no-harm incidents were also found by the Harvard Medical Practice Study method.

Conclusions: Retrospective record review enabled detection of adverse events as well as identification of no harm incidents. It is considered a useful method. There were differences both in agreement between reviewer teams and between review methods. Joint preparations and discussions seemed to increase the level of agreement in judgment between reviewers. By adding retrospective record review for findings of no-harm incidents to conventional incident reporting, healthcare providers can gain new important information about commonly occurring, no-harm incidents in order to improve patient safety.

Place, publisher, year, edition, pages
Växjö: Linnaeus University Press, 2013. , 57 p.
Series
Linnaeus University Dissertations, 153/2013
National Category
Medical and Health Sciences
Research subject
Health and Caring Sciences, Caring Science
Identifiers
URN: urn:nbn:se:lnu:diva-30428ISBN: 978-91-87427-61-9 (print)OAI: oai:DiVA.org:lnu-30428DiVA: diva2:664281
Public defence
2013-12-06, V159, Stagneliusgatan 14, Kalmar, 09:30 (Swedish)
Opponent
Supervisors
Available from: 2013-11-25 Created: 2013-11-14 Last updated: 2013-11-25Bibliographically approved
List of papers
1. Assessment of adverse events in medical care: lack of consistency between experienced teams using the global trigger tool.
Open this publication in new window or tab >>Assessment of adverse events in medical care: lack of consistency between experienced teams using the global trigger tool.
2012 (English)In: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, Vol. 21, no 4, 307-314 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Many patients are harmed as the result of healthcare. A retrospective structured record review is one way to identify adverse events (AEs). One such review approach is the global trigger tool (GTT), a consistent and well-developed method used to detect AEs. The GTT was originally intended to be used for measuring data over time within a single organisation. However, as the method spreads, it is likely that comparisons of GTT safety outcomes between hospitals will occur.

OBJECTIVE: To evaluate agreement in judgement of AEs between well-trained GTT teams from different hospitals.

METHODS: Five teams from five hospitals of different sizes in the southeast of Sweden conducted a retrospective review of patient records from a random sample of 50 admissions between October 2009 and May 2010. Inter-rater reliability between teams was assessed using descriptive and κ statistics.

RESULTS: The five teams identified 42 different AEs altogether. The number of identified AEs differed between the teams, corresponding to a level of AEs ranging from 27.2 to 99.7 per 1000 hospital days. Pair-wise agreement for detection of AEs ranged from 88% to 96%, with weighted κ values between 0.26 and 0.77. Of the AEs, 29 (69%) were identified by only one team and not by the other four groups. Most AEs resulted in minor and transient harm, the most common being healthcare-associated infections. The level of agreement regarding the potential for prevention showed a large variation between the teams.

CONCLUSIONS: The results do not encourage the use of the GTT for making comparisons between hospitals. The use of the GTT to this end would require substantial training to achieve better agreement across reviewer teams.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Health and Caring Sciences
Identifiers
urn:nbn:se:lnu:diva-21843 (URN)10.1136/bmjqs-2011-000279 (DOI)22362917 (PubMedID)2-s2.0-84858753104 (Scopus ID)
Available from: 2012-09-28 Created: 2012-09-28 Last updated: 2017-12-07Bibliographically approved
2. Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus group interviews
Open this publication in new window or tab >>Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus group interviews
Show others...
2013 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, e003131- p.Article in journal (Refereed) Published
Abstract [en]

Objectives The aim was to describe the strengths and weaknesses, from team member perspectives, of working with the Global Trigger Tool (GTT) method of retrospective record review to identify adverse events causing patient harm.

Design A qualitative, descriptive approach with focus group interviews using content analysis.

Setting 5 Swedish hospitals in 2011.

Participants 5 GTT teams, with 5 physicians and 11 registered nurses.

Intervention 5 focus group interviews were carried out with the five teams. Interviews were taped and transcribed verbatim.

Results 8 categories emerged relating to the strengths and weaknesses of the GTT method. The categories found were: Usefulness of the GTT, Application of the GTT, Triggers, Preventability of harm, Team composition, Team tasks, Team members’ knowledge development and Documentation. Gradually, changes in the methodology were made by the teams, for example, the teams reported how the registered nurses divided up the charts into two sets, each being read respectively. The teams described the method as important and well functioning. Not only the most important, but also the most difficult, was the task of bringing the results back to the clinic. The teams found it easier to discuss findings at their own clinics.

Conclusions The GTT method functions well for identifying adverse events and is strengthened by its adaptability to different specialties. However, small, gradual methodological changes together with continuingly developed expertise and adaption to looking at harm from a patient's perspective may contribute to large differences in assessment over time.

National Category
Nursing Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:lnu:diva-30422 (URN)10.1136/bmjopen-2013-003131 (DOI)000330541900016 ()2-s2.0-84885339860 (Scopus ID)
Available from: 2013-11-14 Created: 2013-11-14 Last updated: 2017-12-06Bibliographically approved
3. Is detection of adverses events affected by record review merthodology? an evaluation of the "Harvard medical practice study" method and the "Global trigger tool"
Open this publication in new window or tab >>Is detection of adverses events affected by record review merthodology? an evaluation of the "Harvard medical practice study" method and the "Global trigger tool"
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2013 (English)In: Patient Safety in Surgery, ISSN 1754-9493, E-ISSN 1754-9493, Vol. 7, no April, Article ID: 10- p.Article in journal (Refereed) Published
Abstract [en]

Background

There has been a theoretical debate as to which retrospective record review method is the most valid, reliable, cost efficient and feasible for detecting adverse events. The aim of the present study was to evaluate the feasibility and capability of two common retrospective record review methods, the “Harvard Medical Practice Study” method and the “Global Trigger Tool” in detecting adverse events in adult orthopaedic inpatients.

Methods

We performed a three-stage structured retrospective record review process in a random sample of 350 orthopaedic admissions during 2009 at a Swedish university hospital. Two teams comprised each of a registered nurse and two physicians were assigned, one to each method. All records were primarily reviewed by registered nurses. Records containing a potential adverse event were forwarded to physicians for review in stage 2. Physicians made an independent review regarding, for example, healthcare causation, preventability and severity. In the third review stage all adverse events that were found with the two methods together were compared and all discrepancies after review stage 2 were analysed. Events that had not been identified by one of the methods in the first two review stages were reviewed by the respective physicians.

Results

Altogether, 160 different adverse events were identified in 105 (30.0%) of the 350 records with both methods combined. The “Harvard Medical Practice Study” method identified 155 of the 160 (96.9%, 95% CI: 92.9-99.0) adverse events in 104 (29.7%) records compared with 137 (85.6%, 95% CI: 79.2-90.7) adverse events in 98 (28.0%) records using the “Global Trigger Tool”. Adverse events “causing harm without permanent disability” accounted for most of the observed difference. The overall positive predictive value for criteria and triggers using the “Harvard Medical Practice Study” method and the “Global Trigger Tool” was 40.3% and 30.4%, respectively.

Conclusions

More adverse events were identified using the “Harvard Medical Practice Study” method than using the “Global Trigger Tool”. Differences in review methodology, perception of less severe adverse events and context knowledge may explain the observed difference between two expert review teams in the detection of adverse events.

Place, publisher, year, edition, pages
BioMed Central, 2013
Keyword
Adverse event, safety, retrospective record review, orthopaedic care
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:lnu:diva-30426 (URN)10.1186/1754-9493-7-10 (DOI)2-s2.0-84877036871 (Scopus ID)
Available from: 2013-11-14 Created: 2013-11-14 Last updated: 2017-12-06Bibliographically approved
4. Retrospective record review in proactive patient safety work: identification of no-harm incidents
Open this publication in new window or tab >>Retrospective record review in proactive patient safety work: identification of no-harm incidents
Show others...
2013 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, 282Article, review/survey (Refereed) Published
Abstract [en]

Background: In contrast to other safety critical industries, well-developed systems to monitor safety within the healthcare system remain limited. Retrospective record review is one way of identifying adverse events in healthcare. In proactive patient safety work, retrospective record review could be used to identify, analyze and gain information and knowledge about no-harm incidents and deficiencies in healthcare processes. The aim of the study was to evaluate retrospective record review for the detection and characterization of no-harm incidents, and compare findings with conventional incident-reporting systems. Methods: A two-stage structured retrospective record review of no-harm incidents was performed on a random sample of 350 admissions at a Swedish orthopedic department. Results were compared with those found in one local, and four national incident-reporting systems. Results: We identified 118 no-harm incidents in 91 (26.0%) of the 350 records by retrospective record review. Ninety-four (79.7%) no-harm incidents were classified as preventable. The five incident-reporting systems identified 16 no-harm incidents, of which ten were also found by retrospective record review. The most common no-harm incidents were related to drug therapy (n = 66), of which 87.9% were regarded as preventable. Conclusions: No-harm incidents are common and often preventable. Retrospective record review seems to be a valuable tool for identifying and characterizing no-harm incidents. Both harm and no-harm incidents can be identified in parallel during the same record review. By adding a retrospective record review of randomly selected records to conventional incident-reporting, health care providers can gain a clearer and broader picture of commonly occurring, no-harm incidents in order to improve patient safety.

Keyword
Retrospective record review, Incidents, Patient safety, Harvard medical practice study method
National Category
Nursing
Research subject
Health and Caring Sciences
Identifiers
urn:nbn:se:lnu:diva-28351 (URN)10.1186/1472-6963-13-282 (DOI)000322393500002 ()2-s2.0-84880335272 (Scopus ID)
Available from: 2013-08-22 Created: 2013-08-22 Last updated: 2017-12-06Bibliographically approved

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