Brennan T A, Localio R J, Laird N L
Division of General Medicine, Brigham and Women's Hospital, Boston, MA 02115.
Med Care. 1989 Dec;27(12):1148-58. doi: 10.1097/00005650-198912000-00006.
To evaluate a process for identifying adverse events through review of medical records, multiple reviews of 360 medical records from two teaching hospital were performed. The data from these multiple reviews provided information about the validity and reliability of our two-phase review process. In particular, it was found that the initial phase, involving review of the medical records by medical-record-room administrators using explicit criteria, was valid, with a sensitivity of 84% and negative predictive value of 92%. Results also showed that the second phase, involving judgments by physicians guided by an adverse event analysis form, was reliable (Spearman Brown Rm = 0.78, m = 2) and demonstrated construct validity when compared with a review by a set of senior physicians employing a different method of review (Kappa = 0.57). In addition, it was found that these cases classified as difficult to judge from causation were judged less reliable (Rm = 0.48, for difficult case, Rm = 0.65, for other cases, m = 1). These results indicate that a two-step review process of medical records can produce judgments about adverse events that are both reliable and valid.
为了评估通过审查病历识别不良事件的过程，对两家教学医院的360份病历进行了多次审查。这些多次审查的数据提供了有关我们两阶段审查过程的有效性和可靠性的信息。特别是，发现初始阶段，即由病历室管理人员使用明确标准审查病历，是有效的，灵敏度为84%，阴性预测值为92%。结果还表明，第二阶段，即由医生根据不良事件分析表进行判断，是可靠的（斯皮尔曼-布朗相关系数Rm = 0.78，m = 2），并且与一组采用不同审查方法的资深医生进行的审查相比，具有结构效度（卡帕系数 = 0.57）。此外，发现这些从因果关系判断为难以判断的病例的可靠性较低（对于困难病例，Rm = 0.48，对于其他病例，Rm = 0.65，m = 1）。这些结果表明，病历的两步审查过程可以对不良事件做出可靠且有效的判断。
