ArticleBMJ open2018
Validity and reliability of a medical record review method identifying transitional patient safety incidents in merged primary and secondary care patients' records.
Article in BMJ open, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers, 2 of them syntheses that pooled it.
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Who cites it
9 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- Potential harms of social prescribing: a global umbrella review and dark logic model.BMJ open · 2026Pooled it
- Incidence and influencing factors of tooth discoloration in children using doxycycline: a meta-analysis.Frontiers in pediatrics · 2025Pooled it
- Extracting International Classification of Diseases Codes from Clinical Documentation Using Large Language Models.Applied clinical informatics · 2025Article
- Article
- End of life in patients attended by pediatric palliative care teams: what factors influence the place of death and compliance with family preferences?European journal of pediatrics · 2023Observational
- Article
- Medication-related harm in New Zealand general practice: a retrospective records review.The British journal of general practice : the journal of the Royal College of General Practitioners · 2021Article
- Epidemiology of healthcare harm in New Zealand general practice: a retrospective records review study.BMJ open · 2021Article
- Evaluating the utility and challenges associated with "unknown" and fictional patients in the electronic medical record.Academic pathologyArticle
Corrections and comments
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Authors and funding
7 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveInadequate information transfer during transitions in healthcare is a major patient safety issue. Aim of this study was to pilot a review of medical records to identify transitional safety incidents (TSIs) for use in a large intervention study and assess its reliability and validity.
designA retrospective medical record review study. SETTINGS AND
participantsCombined primary and secondary care medical records of 301 patients who had visited their general practitioner and the University Medical Center Utrecht, the Netherlands, in 2013 were randomly selected. Six trained reviewers assessed these medical records for presence of TSIs. OUTCOMES: To assess inter-rater reliability, 10% of medical records were independently reviewed twice. To assess validity, the identified TSIs were compared with a reference standard of three objectively identifiable TSIs.
resultsThe reviewers identified TSIs in 52 (17.3%) of all transitional medical records. Variation between reviewers was high (range: 3-28 per 50 medical records). Positive agreement for finding a TSI between reviewers was 0%, negative agreement 80% and the Cohen's kappa -0.15. The reviewers identified 43 (22%) of 194 objectively identifiable TSIs.
conclusionThe reliability of our measurement tool for identifying TSIs in transitional medical record performed by clinicians was low. Although the TSIs that were identified by clinicians were valid, they missed 80% of them. Restructuring the record review procedure is necessary.
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