Statewide Identification of Adverse Events Using Retrospective Nurse Review: Methods and Outcomes

• Published in: Journal of nursing measurement Vol. 15; no. 3; pp. 220 - 232
• Main Authors: Silver, Michael P., Hougland, Paul, Elder, Susan, Haug, Jan, Pritchett, Tracey, Donnelly, Steven, Link, Carolyn L., Xu, Wu
• Format: Journal Article
• Language: English
• Published: United States Springer Publishing Company 01.01.2007
• Subjects: Administration, Management, and Leadership; Causality; Clinical Audit - organization & administration; Cost-Benefit Analysis; Evidence-Based Medicine; Hospitals - statistics & numerical data; Humans; International Classification of Diseases - statistics & numerical data; Medical Errors - methods; Medical Errors - prevention & control; Medical Errors - statistics & numerical data; Missouri - epidemiology; Nurse's Role; Nursing; Nursing Education; Nursing Evaluation Research; Observer Variation; Outcome Assessment (Health Care); Patient Discharge - statistics & numerical data; Peer Review, Health Care - methods; Peer Review, Health Care - standards; Physician's Role; Population Surveillance; Professional Issues and Trends; Retrospective Studies; Safety Management; Severity of Illness Index; Total Quality Management; Utah - epidemiology; Utah; Missouri; MEDICAL RECORD; ADVERSE EVENT; NURSE REVIEW; PATIENT SAFETY
• ISSN: 1061-3749; 1945-7049
• DOI: 10.1891/106137407783095784

This study was conducted as part of a two-state study of the validity of hospital discharge data for adverse event (AE) surveillance. Reliability of nurse identification of AEs was assessed through comparison with physician review. Nurses reviewed 6,296 medical records selected from two sampling frames. All were patients in 41 Utah acute care hospitals and surgery patients in 36 Missouri hospitals. A total of 1,035 records were independently reviewed by physicians using the same methods. Overall agreement between nurse and physician findings in Utah and Missouri, at the case level, was 78.5% (238/303) and 68.2% (499/732), respectively. Nurse review of medical records to identify AEs represents a cost-effective alternative to physician review for large-scale and ongoing patient safety improvements and surveillance purposes.