Trigger Tool Research Articles

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis

BackgroundAdverse events (AEs) cause suffering for hospitalised children, a fragile patient group where the delivery of adequate timely care is of great importance.ObjectiveTo report the incidence and characteristics of AEs,...

Exploring nursing-sensitive events in home healthcare: A national multicenter cohort study using a trigger tool

BackgroundThe provision of home healthcare is increasing in response to the growing aging population with the need for chronic disease management in their homes. Safety work differs from hospital care. The incidence of adverse events in home healthcare is sparsely studied but is estimated to occur in-one third of patients, and most are deemed preventable. Although nursing care is crucial for risk assessment and preventive work in the home environment, the role of registered nurses in the prevention of no-harm incidents and adverse events has not received sufficient scientific attention. ObjectivesTo explore nursing-sensitive events in patients receiving home healthcare. Design, setting and participantsA Swedish national multicenter study based on a structured record review of 600 randomly chosen healthcare records from 10 organizations in different regions of the country. MethodsTen trained teams, each including physician(s) and registered nurses, undertook a review based on the Global Trigger Tool method. The review covered a maximum of 90 days from admission to home healthcare. First, each record was screened for the presence of 38 predefined triggers. In the second step, every potential event was assessed according to preventability, types of events, severity, time of occurrence, consequences of the event, and potential contributing causes. ResultsIn total, 699 events were identified in the study. Of these, 495 (74.0%) were classified as nursing-sensitive (227 no-harm incidents and 268 adverse events) and affected 267 (44.5%) patients, with a mean of 1.9 events per patient. The majority (n = 367, 73.1%) were considered preventable. The most prominent types of nursing-sensitive event were falls (n = 138, 27.9%), pressure ulcers (n = 62, 12.5%), healthcare-associated infections (n = 58, 11.7%) and medication management (n = 50, 10.1%). Concerning severity, 45.9% were classified as no-harm incidents and another 36.6% resulted in temporary harm that required extra healthcare resources: 226 hospital days, 66 physician visits in outpatient care, and 99 in home healthcare. All severity types occurred from day 1, except death, which included only one patient. The most frequent contributing factors were deficiencies in nursing care, treatment & diagnosis, with the subgroups nursing care, observation, treatment & follow-up, followed by deficiencies in the organization. ConclusionsNursing-sensitive events in home healthcare are common, often preventable, and occur from the start of the care period. This study contributes to increased knowledge of patient safety shortcomings and points to the important role that registered nurses play in patient safety work.

The Use of Medical Imaging Request Forms as Trigger Tools to Detect Intra-Hospital Adverse Events: A Pilot Study.

To evaluate the contribution of medical imaging request forms as trigger tools to detect patient adverse event (AE) occurring during hospitalization. This is a retrospective study in a single institution. Between January and June 2019, the hospital information system (HIS) was fetched for request forms of radiological examinations performed for inpatients >48 hours after the admission date. The investigated request forms were: Doppler ultrasound of the upper limbs, Doppler ultrasound of the lower limbs, and the repetition of three consecutive requests of chest radiographs within 24 hrs, to detect upper or lower limb venous thrombosis, or AEs related to the respiratory system, respectively. Patients' medical charts and radiological examinations were evaluated to document the presence or absence of an AE. The frequencies of AEs in the three groups of trigger tools were compared to corresponding control groups, matched according to age, sex and length of stay. Among a total of 2798 hospital admissions during the study period, there were 74 files triggered by the three types of radiological request forms. There were 6/24 AE (25%) related to upper limb venous thrombosis, 4/33 (12.1%) AE related to lower limb venous thrombosis, and 6/17 (35.3%) AE related to the respiratory system. For all the trigger tools, the frequency of AE in the study groups was significantly higher than that in the control groups. Medical imaging requests could be used as potential trigger tools to detect adverse events related to hospital stay.

Collaborative improvement project to decrease maternal mortality rate across five hospitals in Saudi Arabia

Maternal morbidities and mortalities remain high globally, yet are preventable events. Maternal haemorrhage is a primary cause of both maternal morbidity and mortality. In this collaborative project, multipronged evidence-based interventions,...

Adverse drug event trigger tool: construction and application of a readyto-use tool at Hue University of Medicine and Pharmacy Hospital

Background: Adverse drug event (ADE) is one of the most common causes of injury to patients, accounting for 19% of adverse events (AEs), particularly among the elderly due to their sensitivity to ADE. Thus, taking ADE detection is the first vital step in improving medication safety. Objective: This study aimed to develop an appropriate modified triggers tool based on Institute for Healthcare Improvement (IHI) Global Trigger tool for Adverse Events detecting potential ADEs in patients at Hue University Hospital. Materials and methods: Using a retrospective study on the medical records of inpatients treated in Hue University of Medicine and Pharmacy Hospital in 2020. Results: The modified ADE trigger tool encompassed 13 triggers. In the screening stage, the ADEs were found in 18 medical records (1.9% of total screening records), and 22 ADEs were identified, in which 19 ADEs were determined as adverse drug reactions (ADRs). The study also found that 17/19 ADRs had not been reported via a spontaneous reporting system (89.5%). The modified ADE Trigger tool’s positive predictive value (PPV) was 0.06. Conclusion: A modified ADE Trigger tool for detecting ADE has been constructed and applied at Hue University of Medicine and Pharmacy Hospital. This study would be the first motivation for further studies that attempt to apply this tool into daily clinical pharmacy activities and emphasize the role of Clinical Pharmacists at the hospital. Key words: Adverse Drug Event, adverse event, geriatrics, clinical pharmacy.

252 Predicting Adverse Events: Site Differences Using the Emergency Department Trigger Tool

We previously validated the triggers in the Emergency Department Trigger Tool (EDTT) against manual review and described performance of the tool for detecting AEs in a single center study. In this interim analysis of data from an ongoing international, multicenter study, we report on performance characteristics of the tool in detecting AEs overall and differences across sites.

53 Multicenter Test of the Emergency Department Trigger Tool: Site Differences in Adverse Events Detected

We have previously described the adverse events (AEs) detected using the Emergency Department Trigger Tool (EDTT). In this interim analysis of data from an ongoing international, multicenter study, we present types of ED AEs detected focusing on similarities and differences across sites in part demonstrating generalizability of this approach.

Current patient safety issues: the role of pharmacovigilance

In the current conditions of the pandemic, the burden on the healthcare system, including the pharmacovigilance system monitoring the safety of pharmacotherapy, has significantly increased in all countries. An integral component in ensuring the safety of pharmacotherapy is the identification and prevention of the development of adverse drug reactions (ADR), which are a serious health problem worldwide. One of the modern problems of healthcare, including pharmacovigilance, was the lack of vaccines and drugs for the treatment and prevention of COVID-19 in the first waves of the pandemic, which led to the use of off-label a large number of drugs (hydroxychloroquine, azithromycin, ivermectin) for the treatment of patients with COVID-19 despite the fact that scientific data their benefits were of poor quality and based on in vitro studies. The accelerated approval of drugs and vaccines to combat the COVID-19 pandemic also highlighted the need for rapid data on the safety of drugs in the post-marketing period. However, despite the fact that pharmacovigilance is developing, it still lags behind the impressive scientific and technological achievements achieved in other areas of medicine. Unfortunately, spontaneous reporting does not assess the true prevalence of ADR well, since reporting indicators can vary significantly depending on the motivation, availability of time, qualifications, fear of punishment and similar factors of the sender. Given these known limitations of the spontaneous messaging method, additional strategies for detecting ADR are often used, including trigger tools, manual viewing of medical records and automated monitoring.

Variation in detected adverse events using trigger tools: A systematic review and meta-analysis

Adverse event (AE) detection is a major patient safety priority. However, despite extensive research on AEs, reported incidence rates vary widely. This study aimed: (1) to synthesize available evidence on AE incidence in acute care inpatient settings using Trigger Tool methodology; and (2) to explore whether study characteristics and study quality explain variations in reported AE incidence. Systematic review and meta-analysis. To identify relevant studies, we queried PubMed, EMBASE, CINAHL, Cochrane Library and three journals in the patient safety field (last update search 25.05.2022). Eligible publications fulfilled the following criteria: adult inpatient samples; acute care hospital settings; Trigger Tool methodology; focus on specialty of internal medicine, surgery or oncology; published in English, French, German, Italian or Spanish. Systematic reviews and studies addressing adverse drug events or exclusively deceased patients were excluded. Risk of bias was assessed using an adapted version of the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Our main outcome of interest was AEs per 100 admissions. We assessed nine study characteristics plus study quality as potential sources of variation using random regression models. We received no funding and did not register this review. Screening 6,685 publications yielded 54 eligible studies covering 194,470 admissions. The cumulative AE incidence was 30.0 per 100 admissions (95% CI 23.9-37.5; I2 = 99.7%) and between study heterogeneity was high with a prediction interval of 5.4-164.7. Overall studies' risk of bias and applicability-related concerns were rated as low. Eight out of nine methodological study characteristics did explain some variation of reported AE rates, such as patient age and type of hospital. Also, study quality did explain variation. Estimates of AE studies using trigger tool methodology vary while explaining variation is seriously hampered by the low standards of reporting such as the timeframe of AE detection. Specific reporting guidelines for studies using retrospective medical record review methodology are necessary to strengthen the current evidence base and to help explain between study variation.

Using the Global Trigger Tool in surgical and neurosurgical patients: A feasibility study.

BackgroundThe Global Trigger Tool (GTT) has become a worldwide used method for estimating adverse events through a retrospective patient record review. However, little is known about the facilitators and the challenges in the GTT-implementation process. Thus, this study followed two aims: First, to apply a comprehensive set of feasibility criteria to qualitatively and systematically assess the GTT-implementation process in three departments of German university hospitals. Second, to identify the facilitators and the obstacles met in the GTT-implementation process and to derive recommendations for supporting other hospitals in implementing the GTT in clinical practice.MethodsThe study used a qualitative documentary method based on process documentation, with written and verbal feedback from the reviewer, as well as evaluating the study sites during the implementation process. The study was conducted in three departments, each in a different German university hospital. The authors applied a comprehensive set of 22 feasibility criteria assessing the level of challenge in GTT implementation. The results were synthesized and they focused on the facilitators and the challenges.ResultsOf these 22 feasibility criteria, nine were assessed as a low-level challenge, eleven regarded as a moderate-level challenge, and two with a problematic level of challenge. In particular, the lack of time and staff resources, the quality of the information in the patient records, organizational procedures, and local issues, posed major challenges in the implementation process. By contrast, the use of local coordinators and an external expert made important contributions to the GTT implementation.ConclusionsConsidering the facilitators and the obstacles beforehand may help with the implementation of the GTT in routine practice. In particular, early and effective planning can reduce or prevent critical challenges in terms of time, staff resources, and organizational aspects.

Extemporaneous Compounding: A Possible Trigger Tool to Detect Potential Health Incidents.

Extemporaneous compounding (EC) involves the preparation of a therapeutic product for specific patient need. However, there is a potential relationship between this procedure and the occurrence of health incidents (HI). The use of trigger tools increases HI identification. This study assessed the performance of EC as a trigger to detect potential health incidents arising from this procedure. A one-month observational and cross-sectional study was performed in internal medicine ward and intensive care unit of medium-sized hospital. Data collection was carried out in 5 stages: all triggered patients with dysphagia or enteral feeding tube with prescription of EC were included; EC executed in prescribed standardized drugs was observed; the procedure was compared with the hospital guide and scientific literature; HI monitoring and their evaluation using WHO and NCC MERP algorithms; a search for pharmaceutical alternatives (PA) that would avoid the observed EC. 197 patients were recruited. Almost half of them were triggered by EC from 84 standardized drugs. 48 patients met the inclusion criteria. 28 adverse drug reactions, 01 therapeutic ineffectiveness, and 29 medication errors were identified. EC as a trigger tool showed a PPV value of 0.38. Only 24 drugs have PA available in the market, which could avoid one third of all observed EC. It was possible to detect potentially HI in one of two patients with enteral feeding tubes using EC as a trigger tool. The use of EC as a trigger tool contributes to identifying potential HI arising from drugs, which have not gotten pharmaceutical alternatives to be administered via enteral feeding tube.

Developing a trigger tool to monitor adverse events during haemodialysis in children: a pilot project

BackgroundWe developed a paediatric haemodialysis trigger tool (pHTT) for application per haemodialysis (HD) session in children receiving intermittent in-centre HD and systematically monitored adverse events.MethodsSingle-centre quality improvement study performed over two 8-week cycles. Data collected prospectively using a ‘per-dialysis session’ pHTT tool including 54 triggers across six domains, adapted from a recently described haemodialysis trigger tool (HTT) for adults. Each trigger was evaluated for level of harm following assessment by two authors. Following a period of training, HD nurses completed the HTT at the end of each dialysis session.ResultsThere were 241 triggers over 182 dialysis sessions, with 139 triggers in 91 HD sessions for 15 children, age range 28–205 months, over an 8-week period (first cycle) and 102 triggers in 91 HD sessions for 13 children, age range 28–205 months, over a further 8-week period (second cycle). After interventions informed by the pHTT, the harm rate per session was significantly reduced from 1.03 (94/91) to 0.32 (29/91), P < 0.001. There was a significant difference between the distribution of triggers by harm category (P < 0.001) and between the proportion of triggers across the various domains of the pHTT (P = 0.004) between the two cycles. No triggers were evaluated as causing permanent harm.ConclusionsThis pilot study demonstrates potential benefits of a bedside tool to monitor adverse events during haemodialysis in children. Thus, following interventions informed by the pHTT, the harm rate per session was significantly reduced. Under standard patient safety systems, the vast majority of triggers identified by the pHTT would remain unreported and perhaps lead to missed opportunities to improve patient safety. We propose the use of a paediatric HTT as part of standard care by centres providing HD to children in the future.Graphical A higher resolution version of the Graphical abstract is available as Supplementary information

Emergency Department Adverse Events Detected Using the Emergency Department Trigger Tool

The Emergency Department Trigger Tool (EDTT) is a novel approach to adverse event detection in the ED. We previously described the derivation, validation, and high-level performance of this tool. Here we further detail adverse events detected to demonstrate the utility of the EDTT and how it might be used for quality improvement. This is a secondary analysis of data from a retrospective observational study. We ran the EDTT (a computerized query for triggers) on 13 months of ED visit data, reviewing 5,582 selected records using a typical 2-tiered trigger tool approach. The adverse events detected were categorized by place of occurrence (in the ED versus present on arrival), severity, omission/commission, and type using a taxonomy with categories, subcategories, and up to 3 cross-cutting modifiers. We present adverse event data in detail, focusing in turn on each of these descriptors (severity, event types, and cross-cutting themes) and highlight opportunities identified for targeted improvement. We identified 458 adverse events occurring in the ED for a 13-month period, 10% of which required urgent intervention. Nearly all (90%) were acts of commission. Events resulting in harm were most often related to medications administered and patient care. Common cross-cutting event types included adverse events related to bleeding, opioids, and the use of propofol. Most adverse events (80%) led to temporary harm. The EDTT identifies a broad spectrum of adverse event types, allowing a review by severity, frequency, and type to better understand existing levels of harm in the ED and identify targets for quality improvement. A multicenter study of the EDTT is currently underway, which will contribute additional power and assess generalizability.

Building Consensus for a Shared Definition of Adverse Events: A Case Study in the Profession of Dentistry.

To achieve high-quality health care, adverse events (AEs) must be proactively recognized and mitigated. However, there is often ambiguity in applying guidelines and definitions. We describe the iterative calibration process needed to achieve a shared definition of AEs in dentistry. Our alignment process includes both independent and consensus building approaches. We explore the process of defining dental AEs and the steps necessary to achieve alignment across different care providers. Teams from 4 dental institutions across the United States iteratively reviewed patient records after identification of charts using an automated trigger tool. Calibration across teams was supported through negotiated definition of AEs and standardization of evidence provided in review. Interrater reliability was assessed using descriptive and κ statistics. After 5 iterative cycles of calibration, the teams (n = 8 raters) identified 118 cases. The average percent agreement for AE determination was 82.2%. Furthermore, the average, pairwise prevalence and bias-adjusted κ (PABAK) was 57.5% (κ = 0.575) for determining AE presence. The average percent agreement for categorization of the AE type was 78.5%, whereas the PABAK was 48.8%. Lastly, the average percent agreement for categorization of AE severity was 82.2% and the corresponding PABAK was 71.7%. Successful calibration across reviewers is possible after consensus building procedures. Higher levels of agreement were found when categorizing severity (of identified events) rather than the events themselves. Our results demonstrate the need for collaborative procedures as well as training for the identification and severity rating of AEs.

TRIGGER TOOLS AND ADVERSE DRUG EVENTS AT A LARGE GENERAL HOSPITAL IN SÃO PAULO/SP, BRAZIL

OBJECTIVE: The aim of this study was to identify the main adverse drug events (ADEs), and its severity in patients of a large public hospital in São Paulo city using trigger tools and to evaluate its performance. METHODS: This is a prospective study with adults hospitalized in the units of Surgical Center, Medical Clinic, Intensive Care Unit, Adult Emergency Room and Obstetrics, during a period of two months (May to June 2021). Clinical records were reviewed using eleven different trigger tools selected from the Global Trigger Tools of the Institute of Healthcare and adapted to the Hospital reality. Only trigger medications were used. The active search was performed using Hospital’s computerized system and when the prescription of a trigger drug was identified, the pharmacist analyzed the patient’s medical record. RESULTS: There were identified 183 patients with trigger medication prescription. Of these 14,7% presented adverse drug event and were admitted at Medical Clinic (48%). The ADEs identified were pruritus/ skin rash, coumarin poisoning/bleeding, anaphylaxis, excessive sedation, and headache. Considering the severity, 93,6% were moderate and 3,7% severe. The drugs with highest incidence of ADEs were morphine and warfarin. The best performing trigger tools were protamine and flumazenil, and the lowest performing were hydrocortisone and promethazine. CONCLUSION: Trigger tools can be used to identify adverse drug reactions. Its use in hospitals improve patients’ medication safety.

Midwives' recognition and response to maternal deterioration: A national cross-sectional study.

Early warning systems (EWS) are used across health care settings as a tool for the early identification of clinical deterioration and to determine the need to escalate care. Early detection of clinical deterioration and appropriate escalation of care in maternity settings is critical to the safety of pregnant women and infants; however, underutilization of EWS tools and reluctance to escalate care have been consistently reported. Little is known about midwives' use of EWS in the Australian context. Using a cross-sectional approach, we elicited the attitudes, beliefs, and behaviors of a purposive sample of Australian midwives (n=87) with respect to the Maternal Early Warning Trigger Tool (MEWT). Participants answered a 25-question Likert scale survey and one open-ended question. Qualitative answers were analyzed using consensus coding. Midwives reported positive attitudes toward the MEWT, describing it as a valuable tool for identifying clinical deterioration, especially when used as an adjunct to clinical judgment. However, midwives also identified training gaps; 25% had received no training, and only half of those who had received training felt it was effective. In addition, professional tension can create a significant barrier to the effective use of the MEWT. Midwives also reported feeling influenced by their peers in their decision-making with respect to use of the MEWT and being afraid they would be chastised for escalating care unnecessarily. Although the MEWT is valued by Australian midwives as a useful tool, barriers exist to its effective use. These include a lack of adequate, ongoing training and professional tension. Improving interdisciplinary collaboration could enhance the use of this tool for the safety of birthing women and their infants.

How safe are paediatric emergency departments? A national prospective cohort study

BackgroundDespite the high number of children treated in emergency departments, patient safety risks in this setting are not well quantified. Our objective was to estimate the risk and type of...

Disparities in Adverse Event Reporting for Hospitalized Children.

Hospitals rely on voluntary event reporting (VER) for adverse event (AE) identification, although it captures fewer events than a trigger tool, such as Global Assessment of Pediatric Patient Safety (GAPPS). Medical providers exhibit bias based on patient weight status, race, and English proficiency. We compared the AE rate identified by VER with that identified using the GAPPS between hospitalized children by weight category, race, and English proficiency. We identified a cohort of patients 2 years to younger than 18 years consecutively discharged from an academic children's hospital between June and October 2018. We collected data on patient weight status from age, sex, height, and weight, race/ethnicity by self-report, and limited English proficiency by record of interpreter use. We reviewed each chart with the GAPPS to identify AEs and reviewed VER entries for each encounter. We calculated an AE rate per 1000 patient-days using each method and compared these using analysis of variance. We reviewed 834 encounters in 680 subjects; 262 (38.5%) had overweight or obesity, 144 (21.2%) identified as Black, and 112 (16.5%) identified as Hispanic; 82 (9.8%) of encounters involved an interpreter. We identified 288 total AEs, 270 (93.8%) by the GAPPS and 18 (6.3%) by VER. A disparity in AE reporting was found for children with limited English proficiency, with fewer AEs by VER ( P = 0.03) compared with no difference in AEs by GAPPS. No disparities were found by weight category or race. Voluntary event reporting may systematically underreport AEs in hospitalized children with limited English proficiency.

Consensus on patient cases for hospitalised children with a high paediatric track and trigger tool score that raises no mounting concern: a Delphi process study

BackgroundPaediatric track and trigger tools (PTTTs) based on vital parameters have been implemented in hospitals worldwide to help healthcare professionals identify signs of critical illness and incipient deterioration in hospitalised...

Body Mass Index Category and Adverse Events in Hospitalized Children.

To identify associations between patient body mass index (BMI) category and adverse event (AE) rate, severity, and preventability in a cohort of children discharged from an academic children's hospital. We identified patients 2 to 17 years old consecutively discharged between June and October 2018. Patient age, sex, height, and weight were used to categorize patients as having underweight, normal weight, overweight, or obesity. We used the Global Assessment of Pediatrics Patient Safety trigger tool to identify AEs, which were scored for harm and preventability. The primary outcome was the rate of AEs; these were compared with Poisson regression. We used multivariable logistic regression to model event preventability. We reviewed 834 encounters in 680 subjects; 51 (7.5%) had underweight, 367 (54.0%) had normal weight, 112 (16.5%) had overweight, and 150 (22.1%) had obesity. Our cohort experienced 270 AEs, with an overall rate of 69.7 (61.8-78.5) AEs per 1000 patient-days: 67.7 (46.4-98.7) in underweight, 70.0 (59.4-82.4) in normal weight, 58.6 (42.5-79.7) in overweight, and 80.4 (62.5-103.6) in obesity, P=.46. No associations were seen between BMI category and AE severity. Children with obesity had an increased rate of preventable AEs (P < .01), but this association did not persist in the multivariable model. In this single-center study, we did not find associations between BMI category and rate, severity, or preventability of AEs.