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. 2021 Sep-Oct;36(5):337-344.
doi: 10.1097/01.JMQ.0000735460.66073.8f.

Reliability of Patient-Report, Physician-Report, and Medical Record Review to Identify Hospital-Acquired Complications: A Prospective Cohort Study

Eshan Fernando  1 , Shail Rawal, Saeha Shin, Karan Bajwa, Janice Kwan, Lauren Lapointe-Shaw, Terence Tang, Adina Weinerman, Fahad Razak, Amol A Verma
Affiliations

Reliability of Patient-Report, Physician-Report, and Medical Record Review to Identify Hospital-Acquired Complications: A Prospective Cohort Study

Eshan Fernando et al. Am J Med Qual. 2021 Sep-Oct.

Abstract

This prospective study of internal medicine inpatients treated at 2 hospitals in Toronto, Canada, between September 1, 2016, and September 1, 2017, compared patient-report, physician-report, and detailed medical record review to identify specific hospital-acquired complications. Six complications were assessed: delirium, catheter-associated urinary tract infection, acute kidney injury, deep vein thrombosis/pulmonary embolism, hospital-acquired pneumonia, or fall. The study included 207 patients and physician responses were obtained for 156 (75%). Complications were identified in 28 (14%) patients by medical record review, 30 (14%) patients by patient-report, and 11 (7%) patients by physician-report. Fifty-four (26%) patients experienced a complication as identified through at least one of the 3 methods. There was little agreement between the 3 methods (Fleiss' ĸ 0.15, P < 0.001). All 3 sources agreed on the occurrence of a specific complication in only 1 patient (1%). Multiple approaches likely are needed to adequately measure hospital-acquired complications.

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