Michel et al listed criteria they used to review hospital charts to screen for adverse events. While most of the criteria are the same as that used by Hiatt et al (above) they use several additional criteria. The authors are from Hopital Xavier Arnozan in France.
Admission and transfers:
(1) unplanned admission as a result of any healthcare management during the 12 months prior to the index admission (failure or unfavorable result of previous medical management)
(2) unplanned transfer to the intensive care unit from a general ward
(3) unplanned transfer to another acute care hospital
General adverse events:
(1) any trauma or injury incurred while in the hospital
(2) adverse drug reaction
(3) documented drug error
(4) hospital acquired infection
(5) excessive pain not adequately managed
(6) psychological or social injury
(7) acute myocardial infarction, cerebrovascular accident, or pulmonary embolus
(8) development of a neurologic deficit not present on admission
(9) cardiac or respiratory arrest while in the hospital
(10) unexpected death, either at the time of admission or at the time of death
(11) any other undesirable outcome
Adverse events on the obstetrical ward or nursery:
(1) maternal injury or complication following abortion or labor and delivery
(2) if newborn, 5 minute Apgar score < 6
(3) neonatal complication following labor and delivery
Adverse events for surgical patients:
(1) unplanned return to the operating room during this admission
(2) unplanned open surgery after a closed or laparoscopic surgery
(3) unplanned removal, injury or repair of an organ or structure during surgery or invasive procedure
Perceived problem with care:
(1) indication of litigation in the medical record
(2) patient or family dissatisfied with care
where:
• I would think any complaint of the nursing or medical staff about the patient's care would justify review.
The presence of one or more of these findings indicates that the medical record should be reviewed.
