[Data collection for quality assurance in neonatology: how do physicians compare to documentation specialists?]. / Datenerhebung für die Qualitätssicherung in der Neonatologie. Wer dokumentiert genauer: Arzte oder spezielle Dokumentationskräfte?

ABSTRACT

BACKGROUND: The quality of data collected for the German nationwide quality assurance program in neonatology is currently unknown. The aim of this study was to compare the quality of data collected by resident physicians with the quality of similar data collected by a dedicated research nurse. METHODS: Data for the German national quality assurance program in neonatology, derived from a cohort of 128 premature newborns with a birth weight <1500 g and/or a gestational age of <30 weeks born in the year 2003, were collected by residents taking care on these patients, and separately by a dedicated research nurse for the European Neonatal Network (EuroNeoNet). The data set collected for both networks included 44 common data items. The two data sets were compared, and any disagreement was double-checked using the chart of the baby to clarify which of the data entries was wrong. Furthermore, as data items are not equally important, a weighted analysis of all mistakes was performed. RESULTS: We found wrong data in 108/128 (84 %) of the data sets collected by the residents, and in 43/128 (34 %) of the data sets collected by the research nurse (p < 0.001). The weighted analysis revealed that residents made more mistakes in 30/44 of collected data items, whereas the research nurse did worse only in 1/44 data items. CONCLUSION: This study shows that the quality of data obtained by our resident physicians was worse than the quality of data obtained by our dedicated research nurse.