A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care

235 Background: The Institute for Healthcare Improvement developed the Global Trigger Tool (GTT) for measuring harm rates over time in 2006. Few studies have been published on the measurement properties of GTT and no studies have assessed the value of adding specific modules to the generic GTT. We, therefore, aimed to determine inter-rater reliability, and to evaluate the effect of interrater variation on the reliability of the generic GTT to detect adverse event rates over time. Furthermore to evaluate the effect of adding an oncology specific module to the generic GTT on number and category of adverse events (AEs) identified. Methods: A retrospective chart review was performed by two teams consisting of two primary reviewers. One team used the general GTT, and the other used an oncology specific GTT (GTTO); consisting of the general GTT module plus an additional oncology module. A random sample of 10 charts was selected every two weeks between all discharged patients from a Department of Oncology in 2010. n=240. All charts were reviewed by both teams using standard GTT methods and measures. AEs per 1,000 admission days and AEs per 100 admissions where used to draw Statistical process control (SPC) charts for evaluation of the patient safety process. Inter-rater variability between review teams was assessed calculating the Kappa Cohen coefficient using data from the identical general GTT module. Results: Reliability between the two teams of reviewers to identify an AE was moderate [K=0.45]. A comparison of SPC charts, using the results from the identical general module, showed that moderate agreement gave rise to different conclusions on the patient safety process between teams. Comparing GTT with GTTO we found no significant difference (CI 95% [0.06-0.08]) in number of identified AEs and an equal distribution of the events on harm categories. GTT and GTTO identified 56 and 57 AEs respectively. Conclusions: Moderate agreement between review teams gave rise to different conclusions on the patient safety process suggesting limited use of the GTT to track harm rates over time. Addition of an oncology specific module showed no significant effect on the total number or distribution of AEs on harm categories.

Introduction. In the past two decades, among the various international initiatives aimed at enhancing the quality of medical care, the greatest number of them is aimed at improving the patient's safety situation. Scientific sources suggest that severe evadable adverse events complicate up to 15% of all hospitalizations, of which approximately 0.7-0.9% of cases can lead to death. It is considered that in perinatal practice, mistakes less frequently lead to adverse events and harm, due to a healthier contingent of patients and the modern paradigm of support for normal and physiological processes, instead of diseases. However, according to scientific literature, up to 1-4% of births are complicated by adverse events, of which up to 2/3 can be considered as preventative.The aim of the research is to determine the content of the major modern organizational tools for identification and registration of adverse events and medical errors in perinatal medicine.Materials and methods. We conducted the content analysis of scientific medical and methodological literature, aimed at identifying the key characteristics and content of organizational instruments for identification and registration of medical errors in perinatal medicine.Research results. Content analysis of printed materials and electronic Internet resources allowed us to determine the main requirements for incident reporting system. The subject of analysis can be any incident of patient safety: a medical error and an adverse event. The review of literature allowed us to reveal the evolution of organizational instruments for registration of adverse events in perinatal medicine. At the lower level, there is the analysis of all cases of deaths of mothers, fetuses and newborns, at the second level – registration of all adverse events with causing harm to the patient; at the third level –registration of near-misses events, the list of which can be personally developed by the department / institution management, adapting the already known tools to their own conditions and to the level of the existing patient safety culture; at the fourth level – registration of the so-called triggers, identification of which in the medical documentation is the basis for its detailed analysis in order to identify the adverse event that occurred during the treatment of patient, and, finally, the fifth level – voluntary reporting of medical errors, occurring at the department. The next, higher level of registration of adverse events and medical errors in perinatal medicine is identification and registration of the so-called uncompleted, timely prevented adverse events. The literature review has shown that most countries have implemented the WHO Maternal Near Miss Tool at the national level. However, it is noted that the main disadvantage of this tool is the lack of registration of uncompleted adverse events associated with the newborn. The standard for detecting adverse medical events was a voluntary incident-reporting system. Yet, these systems in a large number of cases do not reveal the actual frequency of adverse events. Public health researchers found that medical staff volunteered to report only 10-20% of errors, of which from 90 to 95% did not cause any harm to patients. Therefore, hospitals need a more effective way of detecting events that harm patients in order to quantify their degree and severity, as well as determine the effectiveness of the measures taken to improve the patient's safety during the treatment and diagnostic process. In this aspect, the Global Trigger Tool, developed by the Institute for Healthcare Improvement (USA), could be the most effective in assessing the safety of in-patient care provision. This methodology represents a list of triggers (prompts) that are defined for their purpose-oriented search in medical paper / electronic documentation. Perinatal trigger tool includes 8 indicators that may indicate an adverse event associated with pregnancy and childbirth. Currently, the global trigger methodology provides for prospective monitoring of clearly defined indicators online in the application of electronic medical documentation, and retrospective monitoring – in the analysis of medical records after the patient's discharge from the hospital.Conclusions. The latest global trends in the provision of medical care, namely the emphasis on patient safety, require new approaches to address the problem of medical errors and adverse events in perinatal medicine. Incident-reporting systems and the culture of patient safety, essential for their successful operation, should be the key elements of patient safety systems, which are implemented at the hospital, regional and national levels.

BackgroundThere has been a theoretical debate as to which retrospective record review method is the most valid, reliable, cost efficient and feasible for detecting adverse events. The aim of the present study was to evaluate the feasibility and capability of two common retrospective record review methods, the “Harvard Medical Practice Study” method and the “Global Trigger Tool” in detecting adverse events in adult orthopaedic inpatients.MethodsWe performed a three-stage structured retrospective record review process in a random sample of 350 orthopaedic admissions during 2009 at a Swedish university hospital. Two teams comprised each of a registered nurse and two physicians were assigned, one to each method. All records were primarily reviewed by registered nurses. Records containing a potential adverse event were forwarded to physicians for review in stage 2. Physicians made an independent review regarding, for example, healthcare causation, preventability and severity. In the third review stage all adverse events that were found with the two methods together were compared and all discrepancies after review stage 2 were analysed. Events that had not been identified by one of the methods in the first two review stages were reviewed by the respective physicians.ResultsAltogether, 160 different adverse events were identified in 105 (30.0%) of the 350 records with both methods combined. The “Harvard Medical Practice Study” method identified 155 of the 160 (96.9%, 95% CI: 92.9-99.0) adverse events in 104 (29.7%) records compared with 137 (85.6%, 95% CI: 79.2-90.7) adverse events in 98 (28.0%) records using the “Global Trigger Tool”. Adverse events “causing harm without permanent disability” accounted for most of the observed difference. The overall positive predictive value for criteria and triggers using the “Harvard Medical Practice Study” method and the “Global Trigger Tool” was 40.3% and 30.4%, respectively.ConclusionsMore adverse events were identified using the “Harvard Medical Practice Study” method than using the “Global Trigger Tool”. Differences in review methodology, perception of less severe adverse events and context knowledge may explain the observed difference between two expert review teams in the detection of adverse events.

<sec><st>Background</st> The Institute of Healthcare Improvement Global Trigger Tool (GTT) is designed to identify potential harms (triggers) and adverse events (AEs) in healthcare organisations. There is currently no such tool validated for use in Parkinson's disease (PD) patients. In this two-stage project, we firstly adapted the GTT to target this patient group and secondly piloted it in our centre. </sec> <sec><st>Methods</st> The GTT and PD specific trigger tool (PSTT) were initially applied to a cohort of 45 inpatients with PD to compare their relative sensitivities. The PSTT was subsequently piloted by a trained rater in 50 surgical and medical inpatients in a single centre. The outcome measure was AEs per 100 patients per 1000 days. </sec> <sec><st>Findings</st> The PSTT detected 109 triggers in 30 patients, compared with 52 triggers in 21 patients using the GTT, and detected over twice as many AEs. PD patients on a medical vs surgical ward were more likely to experience AEs (82.3 vs 52.2, p=0.03). Medication errors or delays were a significant contributor to AEs. </sec> <sec><st>Conclusion</st> The PSTT provides a quick and sensitive method for identifying potential and actual harms to inpatients with PD. Implementation of such methods will help improve the quality of patient care. </sec>

A voluntary reporting system (VRS) is still used to detect adverse events (AEs) in health-care services in many countries. We attempted to apply the Global Trigger Tool (GTT) for the first time in our country and searched for an answer to the question of whether there could be new triggers. Two hundred and forty inpatient records were selected from total of 1,807 inpatient files in the university obstetrics and gynecology clinic between 2018 and 2020. Twenty files per month were reviewed retrospectively using GTT, an approach developed by the American Institute for Health Development. VRS records of the same period were examined. The data were evaluated according to the National Coordinating Council for Medication Error Reporting and Prevention scale and those in the E, F, G, H, I categories were included. The number of AEs per 1,000 patient days was 47.81, AEs per 1,000 patient hospitalizations was 95.83, and hospitalizations with AEs was 9.58%. In the VRS data, 10 of 85 reporting cases were listed in the E category (Damage is temporary and requires intervention), 6 of them were related to fall of the patient, and 4 of them were related to medical device and material safety. By applying GTT, 45 cases in category E and 35 cases in category F (Damage is temporary and requires hospitalization or prolonged hospitalization) AEs were detected in 23 patients (9.58%). The number of AEs reported was 8.3 times higher in the GTT than with VRS. Healthcare related infection, development of complications from any procedure, APTT>100 Seconds, INR>6, Organ Injury - Repair or Removal, All Kinds of Operative Complications were found to be the most sensitive triggers (PPV = 100). There was no difference between the patients with and without AEs in terms of age and number of hospitalization days (p: 0.707, p: 0.618). The sensitivity rate of vaginal dinoprostone use and CRP elevation (30% and 22%, respectively) was higher than the mean sensitivity rate of GTT triggers (15.6%). The GTT is more effective than VRS in detecting AEs. Using vaginal dinoprostone (propess) and high CRP levels could be used as a trigger. The GTT is a credible and fruitful instrument for determining AEs when adapted to the departmental practices.

Does Skilled Nursing Facility Trigger Tool used with Global Trigger Tool increase its value for adverse events evaluation?

The goal of this study was to measure an adverse event rate and determine the potential usefulness of the Institute for Healthcare Improvement's Global Trigger Tool (GTT). Besides using the GTT to measure the adverse event rate, a comparison was also made with the internal Voluntary Reporting Notification System (VRNS) to identify and compare the strengths and weaknesses of the two approaches. Retrospective data were collected from reported patient safety incidents covering a one-year period at Duzce University Hospital, Turkey. Using a range of selection criteria, a total of 219 patient records were selected and then reviewed by a trained GTT team, to investigate the positive triggers in the content of the patient records. It was determined that adverse events per 1000 patient days totalled 80.72. Adverse events per 100 admissions were 29.39, and the rate of admissions with adverse events was 16.67%. The comparison between the GTT and the VRNS showed that the GTT is 19 times more sensitive than the VRNS in the adverse event evaluation process. This is the first published study of the rate of adverse events in a Turkish healthcare setting using the GTT. It was found that the GTT was applicable in this setting, yielding more accurate measurement of the adverse event rate. However, the content of the GTT should be adjusted regarding the standards and documentations used in the Turkish healthcare system to be more useful.

Introduction Identification and measurement of adverse events (AEs) is crucial for patient safety in order to monitor them over time and to implement quality improvement programs, testing if they are effective. Global Trigger Tool (GTT) has been proposed as a low-cost method, being also the most effective to detect AEs. This study aims to describe the number of triggers, the rate and level of AEs identified by GTT and the most frequent type of AE. Methods The Italian version of the GTT was used. Ten paper-based clinical records (CRs) randomly selected every 2 weeks were reviewed from January to April 2019 by three independent reviewers (two nurses, one doctor) at the Academic Hospital of Udine. The AEs rates calculated are: AEs per 1,000 patient-days, AEs per 100 admissions, percentage of admissions with an AE. AEs were classified by harm levels according to National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Results CRs reviewed were 80. Mean age of the patients was 69.3±16.4, women were 37.5%. Mean hospitalisation was 16.8±15.3. Nine were the cases of re-hospitalisation within 30 days (11.3%). The total number of trigger was 156. AEs were 31, with at least one AE on 27.5% of admissions, 38.8 AEs per 100 admissions and 23 AEs per 1,000 patient-days. AEs with harm level E, F and H were respectively 5 (16.1%), 24 (77.4%) and 2 (6.5%). The most frequent type of AE were hospital acquired infections with 15 cases (48.4%). Conclusions The most frequent type of AE was the hospital acquired infections. Rates and levels of AEs were higher than other international studies, probably because of the limited number of CRs reviewed. Key messages Global Trigger Tool is an effective method to detect adverse patient safety events in order to monitor them over time. The most frequent type of adverse events was the hospital acquired infections.

Objectives:To retrospectively determine the extent and types of adverse drug events (ADEs) from the patient cases sheets and identify the contributing factors of medication errors. To assess causality and severity using the World Health Organization (WHO) probability scale and Hartwig's scale, respectively.Methods:Hundred patient case sheets were randomly selected, modified version of the Institute for Healthcare Improvement (IHI) Global Trigger Tool was utilized to identify the ADEs; causality and severity were calculated utilizing the WHO probability scale and Hartwig's severity assessment scale, respectively.Results:In total, 153 adverse events (AEs) were identified using the IHI Global Trigger Tool. Majority of the AEs are due to medication errors (46.41%) followed by 60 adverse drug reactions (ADRs), 15 therapeutic failure incidents, and 7 over-dose cases. Out of the 153 AEs, 60 are due to ADRs such as rashes, nausea, and vomiting. Therapeutic failure contributes 9.80% of the AEs, while overdose contributes to 4.58% of the total 153 AEs. Using the trigger tools, we were able to detect 45 positive triggers in 36 patient records. Among it, 19 AEs were identified in 15 patient records. The percentage of AE/100 patients is 17%. The average ADEs/1000 doses is 2.03% (calculated).Conclusion:The IHI Global Trigger Tool is an effective method to aid provisionally-registered pharmacists to identify ADEs quicker.

BackgroundThe Global Trigger Tool (GTT),which is a method using “triggers” to review medical record retrospectively to identify possible adverse events. Several studies showed that the GTT was effective. However, there were only a few localized trigger tools that had been established to detect pediatric adverse drug events (ADEs) in China. This study aimed to establish a pediatric trigger tool based on GTT, to examine the performance by detecting pediatric inpatients ADEs in a Chinese hospital (a retrospective review), and to investigate the factors associating with the occurrence of ADEs.MethodsThe triggers were established by three steps including literature search, triggers extraction and revision, and experts investigation. A retrospective cohort study was conducted to detect ADEs by using 200 pediatric inpatient records of Sichuan Provincial People’s Hospital.ResultsThirty-three preliminary triggers were established, and 2 rounds of experts investigation were conducted. Finally, 33 triggers were established. In the retrospective review, the positive trigger rate was 64.0%, while the positive predictive value (PPV) was 24.9%. The occurrence of inpatients with ADEs was 20.5%. ADEs/100 admissions were 49.0. ADEs/1000 patient days were 46.89. The most common ADE categories were leukocyte disorders, skin disorders and platelet disorders. The severity of 39 ADEs was grade 1, 55 ADEs was grade 2, 4 ADEs was grade 3. The highest frequency of ADE-related drugs was antineoplastic, followed by antibacterial. The length of stay and the leukemia in the diagnosed diseases were positively correlated with ADEs.ConclusionsThe 33 pediatric triggers may detect ADEs effectively, but still need to be optimized. This study may provide some references for further research in order to improve the rationality and safety of medication.

Adverse event (AE) surveillance may be enhanced by the Institute for Healthcare Improvement's Global Trigger Tool (GTT). A pilot study of the GTT was conducted in one Veterans Health Administration (VA) facility to assess the rates, types, and harm of AEs detected and to examine the overlap in AE detection between the GTT and existing surveillance mechanisms. GTT guidelines were followed and medical records were reviewed for 17 weeks of acute care hospitalizations. Investigators met monthly, first to adjudicate discordant reviewer categorizations of harm and later to categorize the AEs detected using standardized definitions. GTT-detected AEs were compared with incident reports, Patient Safety Indicators, and the VA Surgical Quality Improvement Program. Medical records were reviewed for 273 of 1980 eligible cases. Using the GTT, a total of 109 AEs were identified. More than 1 of 5 hospitalizations (21%) were associated with an AE. The majority of AEs detected (60%) were minor harms; there were no deaths attributable to medical care. Ninety-six of the 109 AEs (88%) were not detected by other measures. The GTT identified previously undetected AEs at one VA. The GTT has the potential to track AEs and guide quality improvement efforts in conjunction with existing AE surveillance mechanisms.

Many hospitals continue to use incident reporting systems (IRSs) as their primary patient safety data source. The information IRSs collect on the frequency of harm to patients [adverse events (AEs)] is generally of poor quality, and some incident types (e.g. diagnostic errors) are under-reported. Other methods of collecting patient safety information using medical record review, such as the Global Trigger Tool (GTT), have been developed. The aim of this study was to undertake a systematic review to empirically quantify the gap between the percentage of AEs detected using the GTT to those that are also detected via IRSs. The review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies published in English, which collected AE data using the GTT and IRSs, were included. In total, 14 studies met the inclusion criteria. All studies were undertaken in hospitals and were published between 2006 and 2022. The studies were conducted in six countries, mainly in the USA (nine studies). Studies reviewed 22 589 medical records using the GTT across 107 institutions finding 7166 AEs. The percentage of AEs detected using the GTT that were also detected in corresponding IRSs ranged from 0% to 37.4% with an average of 7.0% (SD 9.1; median 3.9 and IQR 5.2). Twelve of the fourteen studies found <10% of the AEs detected using the GTT were also found in corresponding IRSs. The >10-fold gap between the detection rates of the GTT and IRSs is strong evidence that the rate of AEs collected in IRSs in hospitals should not be used to measure or as a proxy for the level of safety of a hospital. IRSs should be recognized for their strengths which are to detect rare, serious, and new incident types and to enable analysis of contributing and contextual factors to develop preventive and corrective strategies. Health systems should use multiple patient safety data sources to prioritize interventions and promote a cycle of action and improvement based on data rather than merely just collecting and analysing information.

Impact of computerized physician order entry on medication errors

Detection of Adverse Events in General Surgery Using the “Trigger Tool” Methodology

Uso de diferentes sistemas de notificación de eventos adversos: ¿mucho ruido y pocas nueces?