Register-Based Research of Adverse Events Revealing Incomplete Records Threatening Patient Safety

Abstract

Inadequate, missing or incorrect patient information is usually related to poor documentation. It has several negative effects on patient care processes, and, thus to quality of care, care continuity, and patient safety. It is one of the causes of patient claims. The aim of this study was to analyze patient safety reports and to find out which documentation hazards are damaging to patient safety. Data consisted of the patient incident reports (n=82 353) from seven health and social care areas from 2007–2016 in Finland. A descriptive analysis was conducted to explore the type of service provider and incidents reporting risks in patient data management and documentation. Adverse events due to patient data management and documentation were unusual; however, 18 cases were documented where patients suffered serious harm. Nearly half of the reports resulted from inadequate, missing or incorrect information. Uniform structures, documentation, and service processes need to be developed.