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Potential value of patient record review to assess and improve patient safety in general practice: A systematic review.

ABSTRACT: BACKGROUND:There is limited research, and guidance, on how to address safety in general practice proactively. OBJECTIVES:This review aimed to synthesize the literature describing the use of patient record review (PRR) to measure and improve patient safety in primary care. The PRR methodologies utilized and the resulting outcomes were examined. METHODS:Searches were conducted using Medline, Embase, CINAHL and PsycINFO in February 2017. Reference lists of included studies and existing review papers were also screened. English language, peer-reviewed studies that utilized PRR to identify patient safety incidents (PSIs) occurring in general practice were included. Two researchers independently extracted data from articles and applied the Quality Assessment Tool for Studies with Diverse Designs. RESULTS:A total of 3265 studies were screened, with 15 included. Trigger tools were the most frequent method used for the PRRs (n?=?6). The mean number of safety incidents per 100 records was 12.6. Within studies, a mean of 30.6% of incidents were associated with severe harm (range 8.6-50%), and a mean of 55.6% of incidents was considered preventable (range 32.7-93.5%). The most commonly identified types of PSIs related to medication and prescribing, diagnosis, communication and treatment. Three studies reported on improvement actions taken after the PRRs. CONCLUSION:This review suggests that PRR may be a promising means of proactively identifying patient safety incidents and informing improvements.

SUBMITTER: Madden C

PROVIDER: S-EPMC6104614 | biostudies-literature | 2018 Dec

REPOSITORIES: biostudies-literature

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Potential value of patient record review to assess and improve patient safety in general practice: A systematic review.

Madden Caoimhe C Lydon Sinéad S Curran Ciara C Murphy Andrew W AW O'Connor Paul P

The European journal of general practice 20181201 1

<h4>Background</h4>There is limited research, and guidance, on how to address safety in general practice proactively.<h4>Objectives</h4>This review aimed to synthesize the literature describing the use of patient record review (PRR) to measure and improve patient safety in primary care. The PRR methodologies utilized and the resulting outcomes were examined.<h4>Methods</h4>Searches were conducted using Medline, Embase, CINAHL and PsycINFO in February 2017. Reference lists of included studies and ...[more]

PMID: 30112925

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Project description:To improve the transparency of the local health care system, treatment cost was recently referenced to disease related groups. Treatment quality must be legally documented in a patient registry, in particular for the highly specialized treatments provided by neurosurgery departments.In 2013 we have installed a patient registry focused on cranial neurosurgery. Surgeries are characterized by indication, treatment, location and other specific neurosurgical parameters. Preoperative state and postoperative outcome are recorded prospectively using neurological and sociological scales. Complications are graded by their severity in a therapy-oriented complication score system (Clavien-Dindo-Grading system, CDG). Results are presented at the monthly clinical staff meeting.Data acquisition compatible with the clinic workflow permitted to include all eligible patients into the registry. Until December 2015, we have registered 2880 patients that were treated in 3959 surgeries and 8528 consultations. Since the registry is fully operational (August 2014), we have registered 325 complications on 1341 patient discharge forms (24%). In 64% of these complications, no or only pharmacological treatment was required. At discharge, there was a clear correlation of the severity of the complication and the Karnofsky Performance Status (KPS, ? = -0.3, slope -6 KPS percentage points per increment of CDG) and the length of stay (? = 0.4, slope 1.5 days per increment of CDG).While the therapy-oriented complication scores correlate reasonably well with outcome and length of stay, they do not account for new deficits that cannot be treated. Outcome grading and complication severity grading thus serve a complimentary purpose. Overall, the registry serves to streamline and to complete information flow in the clinic, to identify complication rates and trends early for the internal quality monitoring and communication with patients. Conversely, the registry influences clinical practice in that it demands rigorous documentation and standard operating procedures.

Dataset Information

Potential value of patient record review to assess and improve patient safety in general practice: A systematic review.

Publications

Potential value of patient record review to assess and improve patient safety in general practice: A systematic review.

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