Quality Improvement in Health Care (한국의료질향상학회지)

Korean Society for Quality in Health Care (한국의료질향상학회)
권호 표지
DOI QR코드

DOI QR Code

Development of Case Review Form for Detecting Adverse Events

위해사건 확인을 위한 증례검토지 개발

  • Ock, Min-su (Department of Preventive Medicine, University of Ulsan College of Medicine) ;
  • Lee, Sang-il (Department of Preventive Medicine, University of Ulsan College of Medicine) ;
  • Kim, Yoon (Institute of Health Policy and Management, Medical Research Center, Seoul National University/ Institute of Health Policy and Management, Seoul National University Medical Research Institute) ;
  • Lee, Jae-ho (Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Lee, Jin-yong (Public Health Medical Service, Seoul National University Boramae Medical Center) ;
  • Jo, Min-woo (Department of Preventive Medicine, University of Ulsan College of Medicine) ;
  • Kim, Seon-ha (Department of Nursing, Dankook University) ;
  • Son, Woo-seung (Department of Preventive Medicine, University of Ulsan College of Medicine) ;
  • Kim, Hyun-joo (Konyang University Hospital)
  • 옥민수 (울산대학교 의과대학 예방의학교실) ;
  • 이상일 (울산대학교 의과대학 예방의학교실) ;
  • 김윤 (서울대학교 의과대학 의료관리학교실 서울대학교 의학연구원 의료관리연구소) ;
  • 이재호 (울산대학교 서울아산병원 응급의학과) ;
  • 이진용 (서울대학교 보라매병원 공공의료사업단) ;
  • 조민우 (울산대학교 의과대학 예방의학교실) ;
  • 김선하 (단국대학교 간호학과) ;
  • 손우승 (울산대학교 의과대학 예방의학교실) ;
  • 김현주 (건양대학교병원)
  • Received : 2014.12.30
  • Accepted : 2015.03.25
  • Published : 2015.06.30
Download PDF
⟨ Previous Next ⟩

Abstract

Objectives: The purpose of this study is to develop a case review form for detecting adverse events through a medical records review in hospitalized patients in South Korea. Methods: To develop the case review form, several literatures were reviewed, first. Through the clinical expert meeting, screening criteria were selected and case review form was developed. Result: The Korean version of case review form consisted of the review form-1 for adverse event screening and form-2 for adverse event identification. The applied methodology for the case review form is determined according to the previous studies. For example, the method used in the first stage review is nurse review. Furthermore, the National Coordinating Council for Medication Errors Reporting and Prevention index is used to categorize disability, and a scale of 1 to 6 was used in the causation scores and preventability scores, respectively. Through the clinical expert meeting, a total of 41 screening criteria were selected. Conclusion: The Korean specific case review form was developed for detecting adverse events in hospitalized patients. The results from this study can be used in a large-scale study regarding the nationwide incidence of adverse events.

Keywords

References

  1. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human. Washington, DC: National Academy Press, 2000.
  2. Unbeck M, Schildmeijer K, Henriksson P, Jurgensen U, Muren O, Nilsson L, et al. Is detection of adverse events affected by record review methodology? an evaluation of the "Harvard Medical Practice Study" method and the "Global Trigger Tool". Patient Saf Surg 2013;7:10. https://doi.org/10.1186/1754-9493-7-10
  3. Lee JH, Lee SI. Patient Safety: The Concept and General Approach. Quality Improvement in Health Care 2009;15:9-18.
  4. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6. https://doi.org/10.1056/NEJM199102073240604
  5. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84. https://doi.org/10.1056/NEJM199102073240605
  6. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216-23. https://doi.org/10.1136/qshc.2007.023622
  7. World Health Assembly Resolution WHA55.18 and related documents: http://www.who.int/patientsafety/about/wha_resolution/en/ Accessed [Oct 30, 2014].
  8. 김석화, 김문숙, 김정은, 이상일, 이재호, 정연이 등. 의료기관의 환자안전활동 지원을 위한 방안 연구 결과 보고서. 서울: 의료기관평가인증원.서울대학교병원; 2011.
  9. Hwang JI, Chin HJ, Chang YS. Characteristics associated with the occurrence of adverse events: a retrospective medical record review using the Global Trigger Tool in a fully digitalized tertiary teaching hospital in Korea. J Eval Clin Pract 2014;20:27-35. https://doi.org/10.1111/jep.12075
  10. The research cycle: measuring harm: http://www.who.int/patientsafety/research/strengthening_capacity/measuring_harm/en/ Accessed [Oct 30, 2014].
  11. Levinson DR. Adverse Event in Hospitals: Methods for Identifying Events. Washington DC: Department of Health and Human Services, Office of Inspector General. 2010.
  12. Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events, 2nd edition. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement, 2009.
  13. WHO. Assessing and tackling patient harm A methodological guide for data-poor hospitals. Geneva, Switzerland: WHO, 2010.
  14. Woloshynowych M, Neale G, Vincent CA. Case record review of adverse events: a new approach. Quality and Safety in Health Care 2003;12:411-5. https://doi.org/10.1136/qhc.12.6.411
  15. Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals II: preventability and clinical context. N Z Med J 2003;116:U624.
  16. 堺 秀人. 醫療事故の全國的發生頻度に關する硏究 厚生勞動省科學硏究費補助金醫療技術評價總合硏究事業, 平成17年度總括硏究報告書. 2-3, 2006.
  17. Vincent C. Patient Safety. Chichester: Wiley, 2006.
  18. Weiler PC, Hiatt HH, Newhouse JP, Johnson WG, Brennan TA, Leape LL. A measure of malpractice. Cambridge, MA: Harvard University Press; 1993.
  19. Worster A, Haines T. Advanced statistics: understanding medical record review (MRR) studies. Acad Emerg Med 2004;11:187-92. https://doi.org/10.1111/j.1553-2712.2004.tb01433.x
  20. Neale G, Woloshynowych M. Retrospective case record review: a blunt instrument that needs sharpening. Qual Saf Health Care 2003;12:2-3. https://doi.org/10.1136/qhc.12.1.2
  21. Levinson DR. Adverse Event in Hospitals: National Incidence among Medicare Beneficiaries. Washington DC: Department of Health and Human Services, Office of Inspector General. 2010.
  22. Lessing C, Schmitz A, Albers B, Schrappe M. Impact of sample size on variation of adverse events and preventable adverse events: systematic review on epidemiology and contributing factors. Qual Saf Health Care 2010;19:e24.