Those of us who have been involved
with mandatory incident reporting systems know that underreporting has been a
significant problem. Voluntary reporting systems typically identify more
opportunities for improvement by identifying near-miss events in addition to
adverse events where harm has occurred. Yet voluntary systems still miss
significant numbers of adverse outcomes, too. One of our biggest issues, then,
is knowing whether we are getting any better at reducing adverse outcomes over
time. Quite frankly, over the years we have seen the numbers of reported
incidents in both types of system increase. Rather than being of sign of
worsening care, that usually means that hospitals and other facilities have
actually been doing a much better job at identifying incidents and adverse
events. That’s where IHI’s Global Trigger Tool for Measuring
Adverse Events comes in. It provides a mechanism that can help
us both measure performance over time and help us identify those system issues
that need the most attention in our organizations.
The concept of the IHI Global
Trigger Tool is that there are certain events or items that can be gleaned from
chart review that are often associated with adverse events (with adverse events
being defined as harm being caused). Those events/items are looked for in the
charts and, if found, the chart is further reviewed to determine if an adverse
event did occur. Again, there is a big difference between a trigger and an
adverse event: a trigger simply raises a flag that there might be an associated adverse
event. The adverse events are recorded. The charts are chosen for review in a
truly random fashion and a finite number of charts are reviewed periodically,
typically 10 charts reviewed every two weeks. This sampling methodology allows
calculation of a crude rate of adverse events that can be charted and compared
(within the same organization) over the long run to determine whether the
organization is seeing improvement. Just as important, however, is that the
pattern of adverse events identified allows the organization to prioritize
where it will spend more of performance improvement and patient safety
resources.
The triggers themselves have been
carefully selected (and refined) to reflect both the frequency and severity of
adverse events encountered in a typical hospital. Though the triggers are
extensive, they do not uncover all the types of adverse events found in a
healthcare system. And keeping the tool and its definitions consistent is what
allows the organization to track performance over time.
The process, as adopted by most
organizations, typically involves having two clinical reviewers (nurses,
pharmacists, etc.) each review 10 charts every two weeks. Review of each chart
is limited to 20 minutes. The reviewers then meet with a designated physician,
who reviews the summary sheets assembled by the clinical reviewers and confirms
whether an adverse event occurred and adds his/her expertise to answer any
questions that may have arisen about the case. Some organizations have chosen
to review more charts or do the reviews less often, but the model of 10 charts
every two weeks lends itself to some nice run charts. The real key is consistency of the reviews. IHI
strongly recommends that the two clinical reviewers and the physician reviewer
of the team be the same reviewers for extended periods of time (eg. for one
full year or more). Obviously the reviewers need to be experienced clinicians and
their time needs to be freed up so they can do these chart reviews. The other
key is maintaining consistency in the chart selection. IHI provides guidelines
for the criteria to be used in chart selection. Some hospital charts are
contained in several volumes but don’t worry – the 20-minute rule means you
just go through that chart for a maximum of 20 minutes. You need not identify
all the adverse events that occurred in every case.
IHI provides good guidelines on how
to best review the charts and actually provides sample charts for training. They
give good guidelines on how the training should be done (typically as a team).
Some issues have arisen about use
of the Global Trigger Tool. Since it requires by definition that “harm”
occurred, it does not identify near-misses that may be important sources of
learning. Similarly, it does not include acts of omission in defining adverse
events, only events arising from commission. But remember, this is only one
tool of many your organization will be using in its patient safety/quality
improvement activities. You should have many other mechanisms for identifying
those sorts of events.
Some have noted that the tool has
never been scientifically “validated”, such as one would require in a tool
being used for screening a population for a certain condition. That’s probably
true but multiple diverse organizations have now used this tool over the years
and found it to be very helpful in the two primary purposes: identifying trends
over time and helping to prioritize areas for improvement. Issues about
consistency and inter-rater reliability are minimized by using the same
reviewers and training as a team.
Others have developed tools that
use electronic triggers. Such tools have been used now for many years to
identify adverse drug events1. Szekendi et al2 developed
such a system at Northwestern University using certain abnormal laboratory
results and pharmacy data as triggers and demonstrated the system can such a
identify many adverse events that might have otherwise gone unreported. In
addition, it has the more important feature of being able to identify issues in
real-time or near-real-time. That allows for reviewers to speak to clinicians
involved in the patient’s care to get more accurate details and context about
the case. Is also can lead to an intervention to prevent harm. That makes
electronic trigger surveillance a powerful tool of the present for some and the
near future for others3. But for most, electronic surveillance will
be only one prong of a multi-pronged strategy to identify opportunities to
intervene.
IHI also provides several other
excellent trigger tools (eg. for adverse events related to drugs, ICU’s,
perioperative, neonatal and outpatient settings). But we think you’ll find the
IHI Global Trigger Tool for Measuring Adverse Events an excellent addition to your
patient safety program. Remember, this is only one of several mechanisms you
need to employ to identify patient safety areas that need improvement. Use it
as one source of data to help identify and prioritize areas for investment of
resources and use it as a rough gauge of progress over time.
1 Classen DC, Pestotnik SL, Evans RS,
et al. Computerized surveillance of adverse drug events in hospital patients.
JAMA 1991; 266: 2847-51
2 Szekendi, M K; Sullivan, C; Bobb,
A; Feinglass, J; Rooney, D; Barnard, C; Noskin, G A Active
surveillance using electronic triggers to detect adverse events in hospitalized patients. Quality & Safety in Health Care. 15(3):184-190, June
2006
3Kilbridge, P M 1; Classen, D C 2 Automated surveillance for adverse events in hospitalized
patients: back to the future. Quality & Safety in Health Care. 15(3):148-149, June
2006
Update: See also our April 15, 2008 Patient Safety Tip of the Week “Computerizing Trigger Tools”
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