IDENTIFYING ADVERSE EVENTS CAUSED BY MEDICAL-CARE - DEGREE OF PHYSICIAN AGREEMENT IN A RETROSPECTIVE CHART REVIEW

Objective: To 1) assess the degree of agreement among physicians on th e cause of previously flagged adverse outcomes and 2) relate the findi ngs to systems of quality assurance and performance assessment and pro posals for no-fault compensation for medical injuries. Design: Observa tional study of 7533 pairs of ''structured implicit'' reviews (subject ive opinions based on guidelines) of medical records done by 127 physi cians working independently. Setting: Random sample of 51 inpatient fa cilities in New York State. Patients: Random sample of inpatient medic al records from the selected facilities. Measurements: 1) Number of ag reed-upon adverse events compared with the number of cases of extreme disagreement and 2) internally and indirectly standardized rates at wh ich physician reviewers found adverse events (injuries to patients cau sed at least in part by medical management). Results: In 12.9% of case s (971 of 7533), the two physicians in a pair had extreme disagreement about the occurrence of an adverse event. These cases outnumbered tho se in which both reviewers found an adverse event (10%; n = 757). Agre ement was highest for wound infections and lowest for adverse events a ttributed to failure to diagnose or lack of therapy. The amount of exp erience the physicians had in reviewing records tended to increase the level of agreement. Even after standardization to the results of the entire sample, individual physicians' rates of finding at least slight evidence of an adverse event varied widely (range, 9.9% to 43.7%) (P < 0.001). Conclusions: Structured implicit reviews produced disagreeme nt on the causes of adverse patient outcomes. If systems of quality as surance, performance audits, or no-fault patient compensation are to s ucceed, methods for overcoming the common tendency toward disagreement among experts must be developed.