Traditional efforts to detect Adverse Events (“AEs”), events that result in patient harm, have focused on voluntary reporting and tracking of errors through incident reports or similar reporting. However, public health researchers have established that only 10 to 20 percent of such errors are ever reported and, of those, 90 to 95 percent cause no harm to patients (Griffin 2009). This data leads to one conclusion: hospitals need a more effective way to identify events that cause harm to patients and to select and test changes to reduce that harm.
In an effort to improve patient safety, KDJ Consultants was honored to assist Baylor Healthcare System based in Dallas, Texas with their Global Trigger Tool project, which identified triggers surrounding AEs to allow healthcare organizations to intervene prior to patient harm. The Global Trigger Tool project was expansive in both time and scope, as it extended over seven years and required review of a total of 18,091 charts. Through their collaboration and use of the Institute for Healthcare Improvement (“IHI”) tool, KDJ Consultants and Baylor succeeded in the development of a training program for the Global Trigger Tool project which produced consistent and reliable results. Using this process, KDJ Consultants and its team of Registered Nurses reviewed patient medical records, abstracted AE data, and entered it into a software program written by the Baylor Healthcare Systems research department. Physicians at Baylor then reviewed a sample of these entries to ensure agreement with the results, which were then shared quarterly with the Baylor healthcare providers, the Board of Directors, and applicable quality committees of the hospitals. Results from this study allowed processes surrounding patient safety to be updated over time culminating in observable improvements across all study modules.
The Global Trigger Tool is used to identify AEs and measure the rate of AEs over time, including the following:
- Adverse Events per 1,000 Patient Days;
- Adverse Events per 100 Admissions; and
- Percent of Admissions with an Adverse Event
AE Triggers were grouped into six modules:
- Care Module
- Medication Module
- Surgical Module
- Intensive Care Module
- Perinatal Module
- Emergency Department Module
Collection of data into the database by module ultimately allowed for simplified high-level review of these events. As a result, the organization designed and implemented improved processes based on AEs more common to their organization, which in turn led to reduced incidence of AEs and improved overall patient safety.
Following the success of this initial effort, Deloitte Consulting contracted with KDJ Consultants to replicate this project for St. Joseph’s System in California, where 1,615 charts were reviewed across hospitals in that system with similar results.
For more information, go to https://www.ihi.org/search?keys=global+trigger+tool
Reference: Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009. (Available at ihi.org)
