Health Information Management

News: OIG identifies nurse/physician medical record review as most effective way to identify adverse events

CDI Strategies, March 18, 2010

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In 2008, the Office of Inspector General (OIG) reviewed a sample of nearly 300 Medicare hospitalizations from two counties in a one-week period in order to analyze current methods of identifying adverse events in hospitals.
According to a report released this month, vulnerabilities exist in both accuracy and completeness of two critical sources of information about events..
The bottom line for CDI specialists: The OIG recommends a “through review of medical records by nurses and/or physicians” as “an effective way to identify [adverse] events…”
The two “critical sources” cited by the OIG are billing data and internal hospital incident reports. The OIG found that diagnosis codes “were inaccurate or absent for seven of the 11 Medicare hospital acquired conditions [HAC] identified by the study.” Such problems, according to the report, could cause inappropriate Medicare payments, and inappropriate collection of HAC/quality data.
The report also states that “hospitals participating in the case study apparently did not have any internal incident reports for 112 of the 120 events (93%), including some of the most serious events involving death or permanent disability to the patients.”
Along with its suggestion that physician/nurse review of medical records helps to identify adverse events, the OIG suggested that CMS and AHRQ look to identify adverse events when conducting government medical record reviews for other purposes such as CERT or QIO reviews.
Read the complete, 60-page report, Adverse Events in Hospitals: Methods for
Identifying Events at the OIG Web site.

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