Patient safety incidents – Quality of recording, preventability and cost effects

Background This study examined the information contained in patient records underlying the incident reports to the Patient Insurance Centre and assessed whether the incidents would have been preventable. Diagnosis of treatment events related to the incidents and how they were recorded in the billing information system were also examined.

Methods The analysis of the study is based on 80 (27%) of the Patient Insurance Centre’s decisions issued in 2015. The cases were analyzed for adverse event entries in the patient document and diagnostic entries as well as the adverse event costs recorded in the billing system.

Results The documentation in patients’ records was incomplete with regard to information provided to the patient concerning treatment options and possible complications. Estimates for preventability were 92.5% for reimbursed cases and 20% for non-reimbursed cases. According to the diagnostic entries, additional visits or reoperations had caused additional costs to the amount of 281 360 €.

Conclusions Accurate documentation is part of the legal protection of both the patient and healthcare staff and a healthcare professional´s duty. It is also important in terms of adverse event cost and preventability assessment.