Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record

Thoroddsen, Ásta; Sigurjónsdóttir, Guðrún; Ehnfors, Margareta; Ehrenberg, Anna

doi:10.1111/j.1471-6712.2012.01004.x

Cited by 32 publications

(29 citation statements)

References 33 publications

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“…The scarce existing literature focuses on pressure ulcers as the only studied AE, revealing that the documented information on AEs is not accurate and incomplete (17)(18) .…”

Section: Introductionmentioning

confidence: 99%

Precisión y exhaustividad del registro de eventos adversos mediante una terminología de interfase

González-Samartino

Delgado‐Hito

Adamuz-Tomás

et al. 2018

Rev. esc. enferm. USP

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Objective:To determine what adverse events, including pressure ulcers, infection of the surgical site and aspiration pneumonia, nurses record in clinical histories, in terms of diagnostic accuracy and completeness, through ATIC. Method: Observational, descriptive, cross-sectional, multicenter study of 64 medical-surgical and semi-critical units of two university hospitals in Catalonia, Spain, during 2015. The diagnostic accuracy was assessed by means of the correspondence between the event declared in the Minimum Basic Data Set and the problem documented by the nurse. The record was considered complete when it contained the risk of the event, prescriptions of care and a record of the evolution. Results: The sample evaluated included 459 records. The accuracy results of pressure ulcers are highly correlated between the nursing diagnosis recorded and that declared in the Minimum Basic Data Set. The accuracy in surgical site infection is moderate, and aspiration resulting in pneumonia is very low. The completeness of results is remarkable, except for the risk of bronchoaspiration. Conclusion: The adverse event recorded by nurses with greatest accuracy is pressure ulcers.

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“…The scarce existing literature focuses on pressure ulcers as the only studied AE, revealing that the documented information on AEs is not accurate and incomplete (17)(18) .…”

Section: Introductionmentioning

confidence: 99%

Precisión y exhaustividad del registro de eventos adversos mediante una terminología de interfase

González-Samartino

Delgado‐Hito

Adamuz-Tomás

et al. 2018

Rev. esc. enferm. USP

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“…In addition, coding standards typically require a documented physician diagnosis in order to be coded in administrative data. There is evidence that physician documentation about some types of adverse events (eg, pressure ulcers) is poor 45,46. This limitation became apparent during our validation study, as there were insufficient cases of pressure ulcers and fall-related injuries identified during 1 fiscal year.…”

Section: Discussionmentioning

confidence: 96%

Validating administrative data for the detection of adverse events in older hospitalized patients

Ackroyd‐Stolarz¹,

Bowles²,

Giffin³

2014

DHPS

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Older hospitalized patients are at risk of experiencing adverse events including, but not limited to, hospital-acquired pressure ulcers, fall-related injuries, and adverse drug events. A significant challenge in monitoring and managing adverse events is lack of readily accessible information on their occurrence.PurposeThe objective of this retrospective cross-sectional study was to validate diagnostic codes for pressure ulcers, fall-related injuries, and adverse drug events found in routinely collected administrative hospitalization data.MethodsAll patients 65 years of age or older discharged between April 1, 2009 and March 31, 2011 from a provincial academic health sciences center in Canada were eligible for inclusion in the validation study. For each of the three types of adverse events, a random sample of 50 patients whose records were positive and 50 patients whose records were not positive for an adverse event was sought for review in the validation study (n=300 records in total). A structured health record review was performed independently by two health care providers with experience in geriatrics, both of whom were unaware of the patient’s status with respect to adverse event coding. A physician reviewed 40 records (20 reviewed by each health care provider) to establish interrater agreement.ResultsA total of 39 pressure ulcers, 56 fall-related injuries, and 69 adverse drug events were identified through health record review. Of these, 34 pressure ulcers, 54 fall-related injuries, and 47 adverse drug events were also identified in administrative data. Overall, the diagnostic codes for adverse events had a sensitivity and specificity exceeding 0.67 (95% confidence interval [CI]: 0.56–0.99) and 0.89 (95% CI: 0.72–0.99), respectively.ConclusionIt is feasible and valid to identify pressure ulcers, fall-related injuries, and adverse drug events in older hospitalized patients using routinely collected administrative hospitalization data. The information is relatively inexpensive and easy to access with no impact on clinical staff.

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“…15 No que se refere aos registros, pesquisas [16][17][18] mostram que é preciso melhorar a precisão e a abrangência nos registros.…”

Section: Discussionunclassified

Perfil sociodemográfico e clínico de pacientes com úlceras venosas acompanhados em ambulatório: estudo transversal descritivo

Eberhardt

Lima²,

Lopes³

et al. 2017

Rev Enferm UFSM

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RESUMO:Objetivo: identificar o perfil sociodemográfico e clínico dos pacientes com úlceras venosas, acompanhados no ambulatório de um hospital universitário do sul do Brasil. Método: estudo transversal descritivo, realizado em um ambulatório de angiologia de um hospital universitário. Os dados foram coletados de 21 pacientes com úlceras venosas, de março a julho de 2015, por meio de um formulário; e analisados por meio de estatística descritiva simples. Resultados: os participantes do estudo, em sua maioria, estavam na faixa etária entre 64 e 72 anos, eram do sexo masculino, da raça branca e aposentados, apresentavam uma úlcera venosa, com período inferior a um ano de existência e sem recidivas. Conclusão: os pacientes com úlcera venosa são, em sua maioria, homens idosos, com uma úlcera venosa recente e sem recidivas. DESCRITORES: Enfermagem; Úlcera varicosa; Perfil de saúde; Assistência ambulatorial. ABSTRACT

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Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record

Cited by 32 publications

References 33 publications

Precisión y exhaustividad del registro de eventos adversos mediante una terminología de interfase

Precisión y exhaustividad del registro de eventos adversos mediante una terminología de interfase

Validating administrative data for the detection of adverse events in older hospitalized patients

Perfil sociodemográfico e clínico de pacientes com úlceras venosas acompanhados em ambulatório: estudo transversal descritivo

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