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The purpose of this article is to assess the reliability of an in‐depth analysis on causation, preventability, and disability by two separate review teams on five selected adverse events in acute hospitals: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator‐associated pneumonia and postoperative wound infection.

The analysis uses a retrospective medical record review of 1,515 patient records by two independent teams in eight acute Belgian hospitals for the year 2005. The Mann‐Whitney U‐test is used to identify significant differences between the two review teams regarding occurrence of adverse events as well as regarding the degree of causation, preventability, and disability of found adverse events.

Team 1 stated a high probability for health care management causation in 95.5 per cent of adverse events in contrast to 38.9 per cent by Team 2. Likewise, high preventability was considered in 83.1 per cent of cases by Team 1 versus 51.7 per cent by Team 2. Significant differences in degree of disability between the two teams were also found for pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis and postoperative wound infection, but not for postoperative sepsis and ventilator‐associated pneumonia.

New insight on the degree of and reasons for the huge differences in adverse event evaluation is provided.

The Audit Commission is the statutory body which oversees the external audit of local authorities and agencies within the National Health Service in England and Wales. As part of its function the Commission reviews the economy, efficiency and effectiveness of services provided by these bodies by undertaking studies and audits of selected topics each year. The study of medical records was one of these.

The purpose of the paper is to determine the instance of errors made in physician dictation of medical records.

Purposive sampling method was employed to select medical transcriptionists (MTs) as “experts” to identify the frequency and types of medical errors in dictation files. Seventy-nine MTs examined 2,391 dictation files during one standard work day, and used a common template to record errors.

The results demonstrated that on the average, on the order of 315,000 errors in one million dictations were surfaced. This shows that medical errors occur in dictation, and quality assurance measures are needed in dealing with those errors.

There was no potential for inter-coder reliability and confirming the error codes assigned by individual MTs. This study only examined the presence of errors in the dictation-transcription model. Finally, the project was done with the cooperation of MTSOs and transcription industry organizations.

Anecdotal evidence points to the belief that records created directly by physicians alone will have fewer errors and thus be more accurate. This research demonstrates this is not necessarily the case when it comes to physician dictation. As a result, the place of quality assurance in the medical record production workflow needs to be carefully considered before implementing a “once-and-done” (i.e. physician-based) model of record creation.

No other research has been published on the presence of errors or classification of errors in physician dictation. The paper questions the assumption that direct physician creation of medical records in the absence of secondary QA processes will result in higher quality documentation and fewer medical errors.

Despite the presence of electronic medical records systems, traditional paper-based methods are often used in many countries to document data and eliminate medical record deficiencies. These methods waste patient and hospital resources. The purpose of this study is to evaluate the traditional deficiency management system and determine the requirements of an electronic deficiency management system in settings that currently use paper records alongside electronic hospital information systems.

This mixed-method study was performed in three phases. First, the traditional process of medical records deficiency management was qualitatively evaluated. Second, the accuracy of identifying deficiencies by the traditional and redesigned checklists was compared. Third, the requirements for an electronic deficiency management system were discussed in focus group sessions.

Problems in the traditional system include inadequate guidelines, incomplete procedures for evaluating sheets and subsequent delays in activities. Problems also included the omission of some vital data elements and a lack of feedback about the documentation deficiencies of each documenter. There was a significant difference between the mean number of deficiencies identified by traditional and redesigned checklists (p < 0.0001). The authors proposed an electronic deficiency management system based on redesigned checklists with improved functionalities such as discriminating deficiencies based on the documenter’s role, providing systematic feedback and generating automatic reports.

Previous studies only examined the positive effect of audit and feedback methods to enhance the documentation of data elements in electronic and paper medical records. The authors propose an electronic deficiency management system for medical records to solve those problems. Health-care policymakers, hospital managers and health information systems developers can use the proposed system to manage deficiencies and improve medical records documentation.

The capacity available to deliver outpatient surgical services is outweighed by the demand. Although additional investment is sometimes needed, better aligning resources, increasing operational efficiency and considering new processes all have a role in improving delivering these services. The purpose of this paper is to evaluate the safety of a physician associate (PA) delivered virtual outpatient department (VOPD) consultation service that was established in a General and Colorectal Surgery Department at an Irish teaching hospital.

A series of low-risk surgical patients were referred by senior surgeons to a PA delivered virtual clinic (VOPD). Medical records belonging to half the included patients were randomly selected for review by two doctors three months following discharge back to primary care to confirm appropriate standards of care and documentation and to audit any recorded adverse incidents or outcomes.

In total, 191 patients had been reviewed by the PA in the VOPD with 159 discharged directly back to primary care. Among the 95 medical records that were reviewed by the NCHDs, there were no recorded adverse incidents after discharge. Medical record keeping was deficient in 1 out of 95 reviewed cases.

Using a PA delivered VOPD consultation appears to have a role in following up patients who have undergone low-risk procedures irrespective of age or co-morbidity when selected appropriately. This may assist in reducing the demand on outpatient services by reducing unnecessary return visits, thereby increasing the capacity for new referrals.

While there are reported examples to date of virtual clinics, these relate to services delivered by registered medical practitioners. Here, the authors demonstrate the acceptability of this model of care in an Irish population as delivered by a PA.

The purpose of this paper is to understand the time spent on various tasks during physician inpatient rounds and to examine the new electronic health records (EHRs) impact on time distribution.

Trained observers shadowed hospital physicians to record times for various tasks before and after EHR implementation.

Electronic records did not improve efficiency. However, task times were redistributed. Physicians spent more time reviewing patient charts using time saved from miscellaneous work.

The study focusses solely on work distribution and the changes it underwent. It does not include quality measures either on patient results or physician satisfaction.

As EHR provides rich information and easier access to patient records, it motivates physicians to spend more time reviewing patient charts. Hospital administrators seeking immediate returns on EHR investment, therefore, may be disappointed.

Unlike previous work, this study was conducted in a non-teaching hospital, providing a task-time comparison without any educational and team factor influence. The result serves as a benchmark for many community hospital managers seeking to address the same issue.

Clinical practice guidelines (CPGs) have been developed for many years with the aim of improving the quality of care. A review of the use of CPGs and assessments of CPG compliance among practitioners so far would aid the understanding of factors influencing CPG compliance. This study seeks to provide this.

A general review and discussion of CPGs in areas of their attributes, benefits and pitfalls were carried out. Articles concerning the assessment of CPG compliance were also reviewed to understand the kind of data collected for such assessments (qualitative vs quantitative), the methods used to collect data (objective versus subjective), and the assessment measures employed (process versus outcome).

A total of 57 CPG compliance assessment studies were reviewed. Almost two‐thirds employed objective methods. Of the subjective assessments, 47 per cent analysed solely quantitative data, 32 per cent analysed solely qualitative information and 21 per cent analysed both. More than four‐fifths of all studies used process measures to determine CPG compliance and only 5 per cent used solely outcome measures.

Depending on the methods used, assessments can help identify various factors influencing CPG compliance. Such factors may be related to the physician, guidelines, health system or patient. A good understanding of these factors and their role in influencing compliance behaviour will help health regulators and administrators plan better and more effective strategies to improve doctors' CPG compliance.

This review looks at the various aspects of CPGs to understand how these influence practitioners' compliance.

Comprehensive geriatric assessment (CGA) is a widely used approach in geriatric care and involves multidisciplinary assessments focused on determining a frail elderly person’s medical, psychological and functional capability to develop an integrated plan for treatment. The purpose of this paper is to describe and scrutinize the CGA implementation process at six acute geriatric departments in three county councils and to study the outcome by the documentation in the patient medical records, and the staff perceptions using CGA.

The paper describes the implementation process stages. Outcome measures were based on patient medical records reviews at baseline and follow-ups at year 1 and year 2. Staff perceptions of using CGA were gathered by a questionnaire at the second follow-up.

The implementation had not yet reached sustainability so the implementation process must continue. Results show that documentation on the different areas increased in year 1, as well as the use of standardized assessment tools. However, results from the reviews for year 2 showed some decrease. Staff considered CGA to have high value for the geriatric patient but pointed out the need for continuing education.

Successful strategies for this implementation were strong support from the managers, small seminars, CGA rounds, good introduction routines for new staff and the use of reminders such as pocket-sized focus cards. A high staff turnover occurred during the study, which probably had a significant negative impact on the results.

Evaluating health information systems is an integral part of the life cycle and development of information systems as it can improve the quality of health care. The purpose of this paper is to introduce a bilingual Web-based repository of health-related software products evaluation tools.

The present paper is an applied-developmental study that includes the stages of analysis, design, implementation and evaluation procedures. By searching valid databases as well as holding focus group meetings with a group of experts, the necessary elements for designing a Web-based repository were identified, and also unified modelling language diagrams were designed by using a visual paradigm. The coding(programming) was conducted based on the Gantlet Web Systems Development Framework at the next stage. Finally, after implementing and testing the system, the content was added to the repository, and then the repository was evaluated in terms of usability testing.

The health informatics evaluation tools (HIET) repository provides a functional and selective environment that facilitates the sharing, online storage and retrieval of assessment tools by the scientific community. The HIET repository is easily accessible at www.hiet.ir/ The website is implemented in structured query language (MySQL), personal homepage. Hypertext Preprocessor (PHP) and Linux, Apache, MySQL, and PHP (LEMP) and supports all major browsers.

The HIET repository, as mentioned earlier, serves as an application environment for sharing, storing and online retrieving the assessment tools of health information systems. Therefore, this tool not only facilitates the search, retrieving and study of many evaluation-related papers, which are time-consuming and stressful for researchers and students but can lead to a faster and more scientific evaluation of information systems.