User guidance
 This presentation can be used to train record screeners and medical reviewers for both
retrospective record review and record review of current in-patients (slides can either
be projected with a beamer or distributed in hard-copy)
 Deliver this training approximately one week before the record review but start
preparing early (rehearsing, preparing training materials, etc.)
 Record screeners and medical reviewers should attend the same training session
 The slides can be used to train screeners and reviewers who have not received any
training and have no experience with record reviews (at least one day for the former
and one to two days for the latter) or for a refresher course for trained and experienced
screeners and reviewers (half a day): the content is the same but the pace of work
varies
 Adapt the slides in line with local requirements as appropriate
 Distribute a “record review of current in-patients protocol” or a “retrospective record
review protocol” (depending on training objective) and a copy of the RF2 form to each
participant at the beginning of the training session
 Provide further training if necessary
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Training of record screeners and medical
reviewers
<insert your name, title and affiliation>
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What and how will you learn?
What:
 Unsafe care and WHO’s response
 Key concepts of patient safety
 The objectives and process of record review
 Your role and responsibilities as a record
screener or medical reviewer
 How to excel in your role: do's and dont‘s
How:
 Facilitator-led presentation
 Questions and discussion
 Quiz
 Hands-on exercise
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What is patient safety?
 Freedom from accidental
injuries during medical care
 Activities to avoid, prevent
or correct any adverse
outcomes which may result
from the delivery of health
care
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Why is patient safety important?
 Every year tens of millions of patients
suffer disabling injuries or death due to
unsafe medical care
 In developed countries 1 in 10 patients
is harmed while receiving hospital care
 We know little for developing countries
but evidence suggests that they are
even more affected by patient harm
 The consequences are millions of
devastated lives and billions of dollars
unnecessarily spent on prolonged
hospitalization,
loss
of
income,
disability and litigation
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The initiative of the World Health Organization
 Against this backdrop, the World Health
Organization called into life the World Alliance
for Patient Safety in 2004
 The Alliance pays particular attention to patient
harm in developing and transitional countries
 Since fact-based knowledge is often rare in
such contexts, the Alliance has developed
simple methods to help local practitioners and
researchers assess and tackle patient harm in
data-poor environments
 You can contribute to successfully conducting
one of these methods by acting as a nominal
group meeting facilitator
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What is a record review?
Record review is the process of
analysing medical records for evidence
of HIs based on a set of criteria
The objective of record review is to…
 identify areas with care problems
 gain data on which to base
interventions/solutions
 raise awareness of patient safety
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Key concepts
Harmful incident (HI)
 Unintended injury or
complication
 Prolonged admission, disability
at discharge or death
 Caused by health-care
management rather than the
disease process
 May or may not be preventable
or caused by negligence (e.g.
post-operation wound infection)
Preventability
 Harm would not have arisen if
standard levels of care had
been used
or
 Event is preventable if
reasonable steps to prevent this
occurrence can be identified
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Key concepts
In-patient
 Patient admitted to a healthcare facility for treatment that
requires at least one overnight
stay
Contributing factor
 A factor in an event, effect, result or
outcome which is similar to a cause
and can relate to the
 Patient (e.g. co-morbidities)
 Task (e.g. lack of
guidelines/protocols or their
use)
 Individual (e.g. lack of
knowledge)
 Team (e.g. poor team-work)
 Environment (e.g. defective or
unavailable equipment)
 Organisation (e.g. poor coordination of overall services)
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Key concepts
Prevalence of HIs
 the ratio on the day of data
collection of the number of
cases with HIs to the total
number of cases:
number of HIs x 100
number of screened records
Incidence of HIs
 the ratio for the year of data
collection of the number of
cases with HIs to the total
number of cases:
number of HIs x 100
number of screened records
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Record review of current in-patients vs.
retrospective record review
Record review of current
in-patients
Sample
Source of
information
Outcome
selected records
from in-patients
on day of data collection
medical records and
information from local
nurse/doctor in charge
Retrospective record review
random sample of inpatients from the year prior
to data collection
only medical records
estimation of current rate estimation of last year's rate of
of HIs (prevalence)
HIs (incidence)
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The record review process
Phase
Record screening
Specifications
 Why: to select cases with high
likelihood of HIs and reduce the
number of records that need to
be reviewed by the medical
reviewer
 Who: trained nurse
 What: screen records and gather
information from staff (the latter
only for record review of current
in-patients)
 How: based on detection criteria
(see method protocol, p. x)
 How long: x hours for x records
Record review
 Why: to review records of ‘highrisk’ cases for evidence of HIs,
preventability, contributing factors
and nature of HIs, among others
 Who: trained physician with
clinical experience in the ward
he/she is assessing
 What: review positively screened
records and gather information
from staff (the latter only for record
review of current in-patients)
 How: based on a comprehensive
questionnaire (RF2)
 How long: x hours for x records
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Zoom in on a record review of current inpatients: IBEAS study
 Scope: 11,426 patients from 58 hospitals in Mexico,
Costa Rica, Peru, Colombia and Argentina
 Design: observational cross-sectional study
 Subjects of study: all patients hospitalized at the time
of the study (“a day” in 2007)
 Case definition: Active HIs on the day of data
collection
 Results:
 10.5% prevalence of active HIs, that is 1,191 of
the 11,426 patients suffered an active HI (almost
60% were preventable)
 HIs related to health-care-associated infections
(37.13%), procedures (28.5%), care (13.4%),
medication (8.23%) and diagnosis (6.15%), or
were not specified (6.52%)
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Zoom in on a retrospective record review:
EMRO/AFRO study
 Scope: records of 18,146 randomly selected patients
from 26 hospitals in Egypt, Jordan, Kenya, Morocco,
Tunisia, Sudan, South Africa and Yemen
 Design: a two-phase retrospective audit of randomly
selected medical records of hospitals.
 Subjects of study: all patients hospitalized in the
selected hospitals in 2005
 Case definition: an HI that occurred in 2005.
 Results:
 incidence rate of 8.2%, that is HIs were found in
1,277 of the 18,146 examined records (83%
were preventable)
 Most frequent HIs related to therapeutic errors
(34.2%), diagnostic errors (19.1%) or were
surgical HIs (18.4%), obstetric HIs (8.6%) or
neonatal HIs (7.5%)
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The role of record screeners*
1. Principal investigator only: study method protocol, present the objective of initiative to facility
managers/stakeholders, receive their approval, check whether record quality is sufficient for
record review (otherwise select another method) and select and train screener/reviewer
2. Team: prepare to explain and conduct the record review and arrange meeting room and
materials
3. Team: explain the objective and procedure of the record review upon arrival at health facility
4. Select and gather relevant records (instructions given in method protocol), write list of names
and note missing records
5. Screen records for specific criteria (see RF1) and consult local staff for additional information
(for record review of current in-patients only)
6. Return negatively screened records to local staff and hand positively screened records
(presence of at least one criteria) to medical reviewer
7. Assist medical reviewer in estimating the incidence/prevalence of HIs and comparing results to
those of previous assessments (for monitoring and improvement only)
8. Return all records, explain next steps, thank staff and help with presenting results to facility
managers
* more comprehensive guidance is provided in the method protocol
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The role of record reviewers*
1. Principal investigator only: study method protocol, present the objective of initiative to
facility managers/stakeholders, receive their approval, check whether record quality is
sufficient for record review (otherwise select another method) and select and train
screener/reviewer
2. Team: prepare to explain and conduct the record review and arrange meeting room and
materials
3. Explain the objective and procedure of the record review upon arrival at the health facility
4. Gather relevant records (instructions given in method protocol), write list of names and note
missing records
5. Complete a copy of the RF2 form for each positively screened record and consult local staff
for additional information (for record review of current in-patients only)
6. Ensure that forms are completed as fully as possible and destroy list of names and first
pages of RF2 forms
7. Calculate the rates of HIs and compare results to those of previous assessments (for
monitoring and improvement only)
8. Return all records, explain next steps, thank involved staff and present results to facility
managers
* more comprehensive guidance is provided in the method protocol
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How to excel in your role: do…
 study the method protocol
 prepare your role thoroughly and well in advance
 clarify potential questions with the principal
investigator
 conduct the record review in a calm environment
and avoid interruptions
 read the HI detection criteria (screener) or the
RF2 form (reviewer) carefully during the review
and do not improvise
 screener: ask the reviewer if you are unsure
about the presence of an HI
 ensure nurse/doctor is aware that the objective
is to examine patient cases not to test him/her
(RR of current in-patients only)
 allow time to build a relationship of trust with
nurse/doctor (record review of current in-patients
only)
 ensure full confidentiality during and after the
record review
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How to excel in your role: do not…
 proceed with a retrospective record review if record
quality is insufficient (inform principal investigator who will
select another method)
 hesitate to request further explanation or information from
the doctor/nurse in charge if needed
 blame staff for bad record quality but rather explain how
to improve
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Questions? Comments?
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Quiz
Instructions
 This is not a pass/fail test but an opportunity
to identify areas requiring further discussion or training.
 Participants discuss each question in small groups (you can use your method
protocol), followed by each group presenting their answers and by a facilitator-led
general discussion.
Questions
 Can you explain the concepts of patient safety, HIs, preventability and
contributing factors in your own words and give examples for each?
 Can you summarize the objective and processes of the form of record review you
will be conducting (record review of current in-patients or retrospective record
review)?
 Can you describe, step-by-step, the tasks you will be performing as a record
screener or medical reviewer?
 Can you explain how to best ensure that the do‘s and don’ts are respected?
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Hands-on exercise
1. Participants split into small groups of record screeners and medical
reviewers.
2. Record screeners receive sample records from the trainer and determine for
each case whether an HI is present or not (based on the screening criteria
in the method protocol).
3. Similarly, medical reviewers receive sample records and confirm/reject for
each case whether HIs are present and, if so, determine their preventability
and contributing factors (based on RF2 form).
4. At the end of the exercise, each group explains the problems they have
faced and the lessons they have learned. The trainer clarifies potential
questions.
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Further information
 For further information, questions or comments contact
<insert your name and telephone number or email>
 Visit the Patient Safety Programme (Research) website at:
http://www.who.int/patientsafety/research/en/
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