Are adverse events related to the completeness of clinical records? Results from a retrospective records review using the Global Trigger Tool.

Clinical record (CR) is a tool for recording details about the patient and the most commonly used source of information for detecting adverse events (AEs). Its completeness is an indicator of the quality of care provided and may provide clues for improving professional practice. The primary aim of this study was to estimate the prevalence of AEs. The secondary aims were to determine the completeness of CRs and to examine the relationship between the two variables. We retrospectively reviewed randomly selected CRs of patients discharged from the Academic Hospital of Udine (Italy) in the departments of general surgery, internal medicine, and obstetrics between July and September 2020. Evaluation was performed using the Global Trigger Tool and a checklist to evaluate the completeness of CRs. The relationship between the occurrence of AEs and the completeness of CRs was analyzed using nonparametric tests. A binomial logistic regression analysis was also performed. We reviewed 291 CRs and identified 368 triggers and 56 AEs. Among them, 16.2% of hospitalizations were affected by at least one AE, with a higher percentage in general surgery. The most common AEs were surgical injuries (42.6%; 24) and care related (26.8%; 15). A significant positive correlation was found between the length of hospital stay and the number of AEs. The average completeness of CRs was 72.9% and was lower in general surgery. The decrease in CR completeness correlated with the increase in the total number of AEs (R = -0.14; P = .017), although this was not confirmed by regression analysis by individual departments. Our results seem to suggest that completeness of CRs may benefit patient safety, so ongoing education and involvement of health professionals are needed to maintain professional adherence to CRs.

How to assure the quality of clinical records? A 7-year experience in a large academic hospital.

INTRODUCTION: Clinical record (CR) is the primary tool used by healthcare workers (HCWs) to record clinical information and its completeness can help achieve safer practices. CR is the most appropriate source in order to measure and evaluate the quality of care. In order to achieve a safety climate is fundamental to involve a responsive healthcare workforce thorough peer-review and feedbacks. This study aims to develop a peer-review tool for clinical records quality assurance, presenting the seven-year experience in the evolution of it; secondary aims are to describe the CR completeness and HCWs' diligence toward recording information in it. METHODS: To assess the completeness of CRs a peer-review tool was developed in a large Academic Hospital of Northern Italy. This tool included measurable items that examined different themes, moments and levels of the clinical process. Data were collected every three months between 2010 and 2016 by appointed and trained HCWs from 42 Units; the hospital Quality Unit was responsible for of processing and validating them. Variations in the proportion of CR completeness were assessed using Cochran-Armitage test for trends. RESULTS: A total of 9,408 CRs were evaluated. Overall CR completeness improved significantly from 79.6% in 2010 to 86.5% in 2016 (p<0.001). Doctors' attitude showed a trend similar to the overall completeness, while nurses improved more consistently (p<0.001). Most items exploring themes, moments and levels registered a significant improvement in the early years, then flattened in last years. Results of the validation process were always above the cut-off of 75%. CONCLUSIONS: This peer-review tool enabled the Quality Unit and hospital leadership to obtain a reliable picture of CRs completeness, while involving the HCWs in the quality evaluation. The completeness of CR showed an overall positive and significant trend during these seven years.

Do medical students and residents impact the quality of patient care? An assessment from different stakeholders in an Italian academic hospital, 2019.

Medical students and residents play an important role in patient care and ward activities, thus they should follow hospital procedures and ensure best practices and patient safety. A survey concerning staff on training was conducted to assess the perceived quality of healthcare from healthcare workers (HCWs), residents, medical students and patients in Udine Academic Hospital, Italy. Between December, 2018 and March, 2019, a 5-point Likert-scale questionnaire was administered in 21 units, covering four thematic areas: patients and medical staff satisfaction with the quality of care provided by residents and students, patient privacy, clinical risk management, patient perception of staff on training. Data analysis included descriptive analysis and ordered logistic regressions. A total of 596/1,863 questionnaires were collected from: HCWs (165/772), residents (110/355), students (121/389), and patients (200/347). Residents were rated high both by patients (median = 5, IQR = 4-5, OR 0.49, 95%CI 0.26-0.93) and HCWs (median = 4, IQR = 3-5, OR 0.14, 95%CI 0.08-0.26), with a lower score for medical students on the same topic, both by patients (median = 4, IQR = 3-5, OR 2.94, 95%CI 1.49-5.78) and HCWs (median = 3, IQR = 2-3, OR 0.41, 95%CI 0.25-0.67). Therefore, the role of staff on training in quality and safety of healthcare deserves integrated regular evaluation, since direct interaction with patients contributes to patients' perception of healthcare.

Professional quality improvement project in vaccination services: results of a 5-year survey.

A voluntary professional quality improvement project involving preventive departments and vaccination centres of an Italian region was carried out through two surveys (in 2001 and in 2006) performed using a quality assessment manual including 12 standards and 157 criteria. After the first survey, a feedback was sent to all participating centres. All six local health authorities participated, as well as all regional vaccination centres, 48 in 2001 and 41 in 2006. The overall adherence rate to the criteria was 56.0% (3258/5820) in 2001 and 74.4% (3784/5085) in 2006. The improvement was obtained without mandatory interventions from regional authorities.

[Clinical and organizational guidelines in university hospitals: a model for classification and analysis of hospital records]. / Atti di indirizzo clinico ed organizzativo di un'azienda ospedaliero universitaria: proposta di un modello di classificazione ed analisi.

Clinical and organizational guidelines in university hospitals: a model for classification and analysis of hospital records.

Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital.

BACKGROUND: The frequency of drug prescription errors is high. Excluding errors in decision making, the remaining are mainly due to order ambiguity, non standard nomenclature and writing illegibility. The aim of this study is to analyse, as a part of a continuous quality improvement program, the quality of prescriptions writing for antibiotics, in an Italian University Hospital as a risk factor for prescription errors. METHODS: The point prevalence survey, carried out in May 26-30 2008, involved 41 inpatient Units. Every parenteral or oral antibiotic prescription was analysed for legibility (generic or brand drug name, dose, frequency of administration) and completeness (generic or brand name, dose, frequency of administration, route of administration, date of prescription and signature of the prescriber). Eight doctors (residents in Hygiene and Preventive Medicine) and two pharmacists performed the survey by reviewing the clinical records of medical, surgical or intensive care section inpatients. The antibiotics drug category was chosen because its use is widespread in the setting considered. RESULTS: Out of 756 inpatients included in the study, 408 antibiotic prescriptions were found in 298 patients (mean prescriptions per patient 1.4; SD +/- 0.6). Overall 92.7% (38/41) of the Units had at least one patient with antibiotic prescription. Legibility was in compliance with 78.9% of generic or brand names, 69.4% of doses, 80.1% of frequency of administration, whereas completeness was fulfilled for 95.6% of generic or brand names, 76.7% of doses, 83.6% of frequency of administration, 87% of routes of administration, 43.9% of dates of prescription and 33.3% of physician's signature. Overall 23.9% of prescriptions were illegible and 29.9% of prescriptions were incomplete. Legibility and completeness are higher in unusual drugs prescriptions. CONCLUSION: The Intensive Care Section performed best as far as quality of prescription writing was concerned when compared with the Medical and Surgical Sections.Nevertheless the overall illegibility and incompleteness (above 20%) are unacceptably high. Values need to be improved by enhancing the safety culture and in particular the awareness of the professionals on the consequences that a bad prescription writing can produce.