Adverse events toolkit. Medical record review methodology
- Collection:
- Health Policy and Services Research
- Alternate Title(s):
- Medical record review methodology
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
- Publication:
- Washington, D.C. : U.S. Department of Health and Human Services, Office of Inspector General, July 2023
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Evaluation Studies as Topic Government Regulation Medical Errors Medical Records Patient Harm Risk Management United States
- Genre(s):
- Technical Report
- Abstract:
- This toolkit provides information about how we conducted medical record reviews to identify patient harm and our decision criteria for adverse events, which may be useful to health care providers and researchers dedicated to patient safety. The toolkit describes the methods used in a recent report, Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018, OEI-06-18-00400, and builds upon a broader series of reports about adverse events in hospitals and other health care settings. Of the 18 reports currently in this series, 7 studies used nurses and physicians to review medical records to identify adverse events (each focused on a different health care setting). The goal of our medical record reviews was to establish a national, point-in-time rate of patient harm. The methodology builds upon the Global Trigger Tool (GTT) methodology developed by the Institute for Healthcare Improvement (IHI), which we adapted and used for screening and flagging medical records for possible patient harm. During the course of our reviews, we recorded internal decisions, researched clinical literature and guidelines, interviewed experts in various fields, and conducted routine calls to gain consensus among reviewers on decisions regarding what constitutes harm and how to categorize harm events. A companion resource, Adverse Events Toolkit: Clinical Guidance for Identifying Harm, describes the clinical decision rules we developed for 29 conditions as well as suggestions for how to identify and document evidence of patient harm.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (23 pages))
- NLM Unique ID:
- 9918716086606676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918716086606676