Detecting medical errors in a tertiary hospital: comparing case note review and administrative database Download PDF

Aim: Medical error is common problem in health care, lead to different kind of harm to patients and also additional cost for health care system. The purpose of this research was to assess the reliability of International classification of disease 10th version (ICD 10) administrative data in identifying health care medical errors. Materials and methods: Case Note Review (CNR) was conducted on 1316 patients’ medical file to extract hospital incidents. Standard forms was used to extract the data through random stratified sampling method in a period of 1 year in a 1000 beds specialty and subspecialty hospital in Tehran, Iran to extract patient safety problems. Patient Safety Indicators (PSIs) derived from ICD10 hospital database are also extracted from the same sample size. Two methods were compared using kappa factor. Results: According to the outcomes of patient record review, 5.4% of the hospital’s inpatients, exposed to at least one incidence related to one of AHRQ PSIs, while ICD 10 administrative data only showed 1.35% of inpatients exposed to at least one incidence. Conclusions: This study results shown that use of ICD 10 administrative database to extract medical errors needs major considerations.