van Melle Marije A, Zwart Dorien L M, Poldervaart Judith M, Verkerk Otto Jan, Langelaan Maaike, van Stel Henk F, de Wit Niek J
Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands.
Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
BMJ Open. 2018 Aug 13;8(8):e018576. doi: 10.1136/bmjopen-2017-018576.
Inadequate information transfer during transitions in healthcare is a major patient safety issue. Aim of this study was to pilot a review of medical records to identify transitional safety incidents (TSIs) for use in a large intervention study and assess its reliability and validity.
A retrospective medical record review study.
Combined primary and secondary care medical records of 301 patients who had visited their general practitioner and the University Medical Center Utrecht, the Netherlands, in 2013 were randomly selected. Six trained reviewers assessed these medical records for presence of TSIs.
To assess inter-rater reliability, 10% of medical records were independently reviewed twice. To assess validity, the identified TSIs were compared with a reference standard of three objectively identifiable TSIs.
The reviewers identified TSIs in 52 (17.3%) of all transitional medical records. Variation between reviewers was high (range: 3-28 per 50 medical records). Positive agreement for finding a TSI between reviewers was 0%, negative agreement 80% and the Cohen's kappa -0.15. The reviewers identified 43 (22%) of 194 objectively identifiable TSIs.
The reliability of our measurement tool for identifying TSIs in transitional medical record performed by clinicians was low. Although the TSIs that were identified by clinicians were valid, they missed 80% of them. Restructuring the record review procedure is necessary.
医疗保健过渡期间信息传递不足是一个重大的患者安全问题。本研究的目的是试行对病历进行审查，以识别过渡安全事件（TSIs），供大型干预研究使用，并评估其可靠性和有效性。
一项回顾性病历审查研究。
随机选取了2013年访问过荷兰乌得勒支大学医学中心及其全科医生的301名患者的初级和二级医疗保健综合病历。六名经过培训的审查员评估这些病历中是否存在过渡安全事件。
为评估评分者间信度，对10%的病历进行了两次独立审查。为评估效度，将识别出的过渡安全事件与三个客观可识别的过渡安全事件的参考标准进行比较。
审查员在所有过渡病历中的52份（17.3%）中识别出了过渡安全事件。审查员之间的差异很大（范围：每50份病历为3 - 28例）。审查员之间发现过渡安全事件的阳性一致性为0%，阴性一致性为80%，科恩kappa系数为 - 0.15。审查员识别出了194个客观可识别的过渡安全事件中的43个（22%）。
临床医生用于识别过渡病历中过渡安全事件的测量工具的可靠性较低。尽管临床医生识别出的过渡安全事件是有效的，但他们遗漏了其中的80%。有必要对病历审查程序进行调整。
