Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not?

BACKGROUND: Hospitals routinely survey patients about the quality of care they receive, but little is known about whether patient interviews can detect adverse events that medical record reviews do not. OBJECTIVE: To compare adverse events reported in postdischarge patient interviews with adverse events detected by medical record review. DESIGN: Random sample survey. SETTING: Massachusetts, 2003. PATIENTS: Recently hospitalized adults. MEASUREMENTS: By using parallel methods, physicians reviewed postdischarge interviews and medical records to classify hospital adverse events. RESULTS: Among 998 study patients, 23% had at least 1 adverse event detected by an interview and 11% had at least 1 adverse event identified by record review. The kappa statistic showed relatively poor agreement between interviews and medical records for occurrence of any type of adverse event (kappa = 0.20 [95% CI, 0.03 to 0.27]) and somewhat better agreement between interviews and medical records for life-threatening or serious events (kappa = 0.33 [CI, 0.20 to 0.45]). Record review identified 11 serious, preventable events (1.1% of patients). Interviews identified an additional 21 serious and preventable events that were not documented in the medical record, including 12 predischarge events and 9 postdischarge events, in which symptoms occurred after the patient left the hospital. LIMITATIONS: Patients had to be healthy enough to be interviewed. Delay in reaching patients (6 to 12 months after discharge) may have resulted in poor recall of events during the hospital stay. CONCLUSION: Patients report many events that are not documented in the medical record; some are serious and preventable. Hospitals should consider monitoring patient safety by adding questions about adverse events to postdischarge interviews.

Hospital workload and adverse events.

CONTEXT: Hospitals are under pressure to increase revenue and lower costs, and at the same time, they face dramatic variation in clinical demand. OBJECTIVE: : We sought to determine the relationship between peak hospital workload and rates of adverse events (AEs). METHODS: A random sample of 24,676 adult patients discharged from the medical/surgical services at 4 US hospitals (2 urban and 2 suburban teaching hospitals) from October 2000 to September 2001 were screened using administrative data, leaving 6841 cases to be reviewed for the presence of AEs. Daily workload for each hospital was characterized by volume, throughput (admissions and discharges), intensity (aggregate DRG weight), and staffing (patient-to-nurse ratios). For volume, we calculated an "enhanced" occupancy rate that accounted for same-day bed occupancy by more than 1 patient. We used Poisson regressions to predict the likelihood of an AE, with control for workload and individual patient complexity, and the effects of clustering. RESULTS: One urban teaching hospital had enhanced occupancy rates more than 100% for much of the year. At that hospital, admissions and patients per nurse were significantly related to the likelihood of an AE (P < 0.05); occupancy rate, discharges, and DRG-weighted census were significant at P < 0.10. For example, a 0.1% increase in the patient-to-nurse ratio led to a 28% increase in the AE rate. Results at the other 3 hospitals varied and were mainly non significant. CONCLUSIONS: Hospitals that operate at or over capacity may experience heightened rates of patient safety events and might consider re-engineering the structures of care to respond better during periods of high stress.