PMID- 37952101
OWN - NLM
STAT- MEDLINE
DCOM- 20231129
LR  - 20231129
IS  - 1464-3677 (Electronic)
IS  - 1353-4505 (Linking)
VI  - 35
IP  - 4
DP  - 2023 Nov 27
TI  - Are adverse events related to the completeness of clinical records? Results from 
      a retrospective records review using the Global Trigger Tool.
LID - mzad094 [pii]
LID - 10.1093/intqhc/mzad094 [doi]
AB  - Clinical record (CR) is a tool for recording details about the patient and the 
      most commonly used source of information for detecting adverse events (AEs). Its 
      completeness is an indicator of the quality of care provided and may provide 
      clues for improving professional practice. The primary aim of this study was to 
      estimate the prevalence of AEs. The secondary aims were to determine the 
      completeness of CRs and to examine the relationship between the two variables. We 
      retrospectively reviewed randomly selected CRs of patients discharged from the 
      Academic Hospital of Udine (Italy) in the departments of general surgery, 
      internal medicine, and obstetrics between July and September 2020. Evaluation was 
      performed using the Global Trigger Tool and a checklist to evaluate the 
      completeness of CRs. The relationship between the occurrence of AEs and the 
      completeness of CRs was analyzed using nonparametric tests. A binomial logistic 
      regression analysis was also performed. We reviewed 291 CRs and identified 368 
      triggers and 56 AEs. Among them, 16.2% of hospitalizations were affected by at 
      least one AE, with a higher percentage in general surgery. The most common AEs 
      were surgical injuries (42.6%; 24) and care related (26.8%; 15). A significant 
      positive correlation was found between the length of hospital stay and the number 
      of AEs. The average completeness of CRs was 72.9% and was lower in general 
      surgery. The decrease in CR completeness correlated with the increase in the 
      total number of AEs (R = -0.14; P = .017), although this was not confirmed by 
      regression analysis by individual departments. Our results seem to suggest that 
      completeness of CRs may benefit patient safety, so ongoing education and 
      involvement of health professionals are needed to maintain professional adherence 
      to CRs.
CI  - (c) The Author(s) 2023. Published by Oxford University Press on behalf of 
      International Society for Quality in Health Care. All rights reserved. For 
      permissions, please e-mail: journals.permissions@oup.com.
FAU - Scarpis, Enrico
AU  - Scarpis E
AUID- ORCID: 0000-0002-1471-486X
AD  - Dipartimento di Area Medica, Universita degli Studi di Udine, Udine 33100, 
      Italia.
FAU - Cautero, Peter
AU  - Cautero P
AD  - Dipartimento di Area Medica, Universita degli Studi di Udine, Udine 33100, 
      Italia.
FAU - Tullio, Annarita
AU  - Tullio A
AD  - SOC Istituto di Igiene ed Epidemiologia Valutativa, Azienda Sanitaria 
      Universitaria Friuli Centrale, Udine 33100, Italia.
FAU - Mellace, Flavio
AU  - Mellace F
AD  - Dipartimento di Area Medica, Universita degli Studi di Udine, Udine 33100, 
      Italia.
FAU - Farneti, Federico
AU  - Farneti F
AD  - SOC Rischio Clinico, Qualita e Accreditamento, Azienda Sanitaria Universitaria 
      Friuli Centrale, Udine 33100, Italia.
FAU - Londero, Carla
AU  - Londero C
AD  - SOC Rischio Clinico, Qualita e Accreditamento, Azienda Sanitaria Universitaria 
      Friuli Centrale, Udine 33100, Italia.
FAU - Cocconi, Roberto
AU  - Cocconi R
AD  - SOC Rischio Clinico, Qualita e Accreditamento, Azienda Sanitaria Universitaria 
      Friuli Centrale, Udine 33100, Italia.
FAU - Brunelli, Laura
AU  - Brunelli L
AUID- ORCID: 0000-0002-5475-0021
AD  - Dipartimento di Area Medica, Universita degli Studi di Udine, Udine 33100, 
      Italia.
AD  - SOC Rischio Clinico, Qualita e Accreditamento, Azienda Sanitaria Universitaria 
      Friuli Centrale, Udine 33100, Italia.
LA  - eng
PT  - Journal Article
PT  - Review
PL  - England
TA  - Int J Qual Health Care
JT  - International journal for quality in health care : journal of the International 
      Society for Quality in Health Care
JID - 9434628
SB  - IM
MH  - Humans
MH  - *Medical Errors
MH  - Retrospective Studies
MH  - *Patient Safety
MH  - Hospitalization
MH  - Hospitals
OTO - NOTNLM
OT  - adverse event
OT  - clinical record
OT  - global trigger tool
OT  - patient safety
OT  - quality
OT  - risk management
EDAT- 2023/11/12 06:41
MHDA- 2023/11/29 06:42
CRDT- 2023/11/12 03:40
PHST- 2023/02/23 00:00 [received]
PHST- 2023/09/15 00:00 [revised]
PHST- 2023/11/09 00:00 [accepted]
PHST- 2023/11/29 06:42 [medline]
PHST- 2023/11/12 06:41 [pubmed]
PHST- 2023/11/12 03:40 [entrez]
AID - 7408629 [pii]
AID - 10.1093/intqhc/mzad094 [doi]
PST - ppublish
SO  - Int J Qual Health Care. 2023 Nov 27;35(4):mzad094. doi: 10.1093/intqhc/mzad094.