Association of admission and patient characteristics with quality of discharge letters: posthoc analysis of a retrospective study.

BACKGROUND: A complete, correct and timely discharge letter can communicate important information from the hospital to the general practitioner. The adequacy of the letter may vary with the patient and admission characteristics of the patient. Insight in the association between these characteristics and the presence and quality of the discharge letter will give rise to improvement activities for a better continuity of care after discharge. The objective was to determine the presence, correctness and timeliness of admission information in discharge letters and to determine the association between patient and admission characteristics, including unplanned readmissions and the quality of the discharge letter. METHODS: A post-hoc analysis of a two-staged retrospective patient record review study was performed in 4048 patient records in a random sample of 20 hospitals. RESULTS: Nearly ten percent of the discharge letters are lacking in patient records in Dutch hospitals. In 59.1% of the discharge letters, one or more relevant components are missing. Important laboratory results, relevant information about consultations, answers to the questions of the referrer, changes in medication and follow up are often lacking. Discharge letters are more likely to be missing in elective patient admissions to a hospital, with a shorter length of stay, less comorbidity, and in readmissions. There was a significant variation in missing discharge letters between hospitals and between hospital departments. CONCLUSIONS: The quality of discharge letters varies with patient and admission characteristics.

The ecometric properties of a measurement instrument for prospective risk analysis in hospital departments.

BACKGROUND: Safety management systems have been set up in healthcare institutions to reduce the number of adverse events. Safety management systems use a combination of activities, such as identifying and assessing safety risks in the organizational processes through retrospective and prospective risk assessments. A complementary method to already existing prospective risk analysis methods is Tripod, which measures latent risk factors in organizations through staff questionnaires. The purpose of this study is to investigate whether Tripod can be used as a method for prospective risk analysis in hospitals and whether it can assess differences in risk factors between hospital departments. METHODS: Tripod measures risk factors in five organizational domains: (1) Procedures, (2) Training, (3) Communication, (4) Incompatible Goals and (5) Organization. Each domain is covered by 15 items in the questionnaire. A total of thirteen departments from two hospitals participated in this study. All healthcare staff working in the participating departments were approached. The multilevel method ecometrics was used to evaluate the validity and reliability of Tripod. Ecometrics was needed to ensure that the differences between departments were attributable to differences in risk at the departmental level and not to differences between individual perceptions of the healthcare staff. RESULTS: A total of 626 healthcare staff completed the questionnaire, resulting in a response rate of 61.7%. Reliability coefficients were calculated for the individual level and department level. At the individual level, reliability coefficients ranged from 0.78 to 0.87, at the departmental level they ranged from 0.55 to 0.73. Intraclass correlations at the departmental level ranged from 3.7% to 8.5%, which indicate sufficient clustering of answers within departments. At both levels the domains from the questionnaire were positively interrelated and all significant. CONCLUSIONS: The results of this study show that Tripod can be used as a method for prospective risk analysis in hospitals. Results of the questionnaire provide information about latent risk factors in hospital departments. However, this study also shows that there are indications that the method is not sensitive enough to detect differences between hospital departments. Therefore, it is important to be careful when interpreting differences in potential risks between departments when using Tripod.

What are the safety risks for patients undergoing treatment by multiple specialties: a retrospective patient record review study.

BACKGROUND: If multiple medical specialties are involved in treatment there is a danger of increasing risks to patient safety. This is due to the need for greater co-ordination and communication with other specialties, less emergency cover for individual sub-specialties, and a drop in general care and the overview of care. This study aims to determine if the number of medical specialties treating a patient is associated with the risk of experiencing harm during hospital admission. METHODS: We performed a retrospective patient record review study using a stratified sample of 20 hospitals in the Netherlands. In each hospital 200 patient admissions were included. We related the occurrence of preventable adverse events and non-preventable adverse events to the number of specialties treating a patient through a stepwise multilevel logistic regression analysis. RESULTS: Compared to patients treated by only one specialty, patients treated by three or more specialties had an odds ratio of experiencing an adverse event of 3.01 (95% CI 2.09 to 4.34), and an odds ratio of experiencing a preventable adverse event of 2.78 (95% CI 1.77 to 4.37). After adding characteristics related to the patient and the type of health care, the odds ratio for non-preventable adverse events decreased to 1.46 (95% CI 0.95 to 2.26), and for preventable adverse events to 2.31 (95% CI 1.40 to 3.81). There were no large differences found between the groups relating to the causes of preventable adverse events. However, in patients treated by three or more specialties, the greater number of preventable adverse events was related to the diagnostic process. CONCLUSIONS: The more specialties treating a patient the greater the risk of an adverse event. This finding became more pronounced for preventable adverse events than for non-preventable adverse events after corrections for the characteristics of the patient and their health care. This study highlights the importance of taking the number of specialties treating a patient into account. More research is needed to gain insight into the underlying causes of inadequate care when multiple specialties are required to treat a patient. This could result in appropriate solutions resulting in improvements to care.

Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a retrospective patient record review study.

OBJECTIVE: Adverse event studies often use patient record review as a way to assess patient safety. As this is a time-consuming method, hospitals often study inpatient deaths. In this article we will assess whether this offers a representative view of the occurrence of adverse events in comparison to patients who are discharged while still living. DESIGN: Retrospective patient record review study. SETTING AND PARTICIPANTS: A total of 11,949 hospital admissions; 50% of inpatient deaths; the other half of patients discharged while alive. The data originated from our two national adverse event studies in 2004 and 2008. MAIN OUTCOME MEASURES: Overall adverse events and preventable adverse events in inpatient deaths, and in admissions of patients discharged alive. We looked at size, preventability, clinical process and type of adverse events. RESULTS: Patients who died in hospital were on an average older, had a longer length of stay, were more often urgently admitted and were less often admitted to a surgical unit. We found twice as many adverse events and preventable adverse events in inpatient deaths than in patients discharged alive. Consistent with the differences in patient characteristics, preventable adverse events in inpatient deaths were proportionally less and were often related to the surgical process. Most types of adverse events and preventable adverse events occur in inpatient deaths as well as in patients discharged alive; however, these occur more often in inpatient deaths and are differently distributed. CONCLUSIONS: Reviewing patient records of inpatient deaths is more efficient in identifying preventable AEs than reviewing records of those discharged alive. Although many of the same types of adverse events are found, it does not offer a representative view of the number or type of adverse events.

Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review study.

OBJECTIVE: To determine the change in adverse event (AE) rates and preventable AE rates over time, identify certain patient risk groups and discuss factors influencing the outcome. DESIGN: Longitudinal retrospective patient record review study. SETTING AND PARTICIPANTS: A random sample of 21 hospitals in The Netherlands in 2004, and 20 hospitals in 2008. In each hospital, 400 patient admissions were included in 2004, and 200 in 2008. MAIN OUTCOME MEASURES: AEs and preventable AEs. RESULTS: Multilevel analyses of 11 883 patient records (7.887 in 2004, 3.996 in 2008) showed that the rate of patients experiencing an AE increased from 4.1% (95% CI 3.3% to 5.1%) in 2004 to 6.2% (95% CI 5.0% to 7.6%) in 2008. The preventable AE rate remained relatively stable at 1.8% (95% CI 1.3% to 2.4%) in 2004 and 1.6% (95% CI 1.2% to 2.3%) in 2008. The risk of experiencing a preventable AE was increasingly higher for patients admitted to a surgical unit (OR 1.54 (95% CI 1.10 to 2.16) in 2004 and 3.32 (95% CI 2.17 to 5.07)) in 2008. More than 50% of all AEs were related to surgery. Indications were found that differences in the risk of experiencing a preventable AE between hospital departments were larger in 2008 than in 2004, while differences between hospitals themselves were smaller. CONCLUSIONS: Patient harm related to healthcare is a persistent problem that is hard to influence. Measuring AEs over time stresses the continuing urgency, and also identifies possible areas for improvement.