Are adverse events related to the completeness of clinical records? Results from a retrospective records review using the Global Trigger Tool.
Identifying, measuring and tracking adverse events is an important component of continuous safety improvement. This retrospective study used the Global Trigger Tool to evaluate the prevalence of adverse events documented in clinical records among general surgery, internal medicine and obstetric patients at one Italian hospital. The researchers found that 16% of hospitalizations included at least one adverse event, with the most common being surgical injuries (43%). The researchers observed that completeness of the clinical records correlated with fewer adverse events and emphasized the importance of record completeness and the use of electronic systems to improve adverse event detection.