Trigger Tools

Trigger Tools

4th February 2009

Presenter: Liz Baines

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Patient Safety – The FactsMain Causes of Death:1. Cardiovascular Disease

2. Cancer

3. Respiratory Disease

4. Adverse Events

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What is an Adverse Event?

“An unintended injury or complication caused by medical management rather than the disease process. The injury is sufficiently serious to lead to prolongation of hospitalisation or temporary of permanent impairment or disability in the patient”

Harvard Medical Practice Study 1990

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A Safety Culture in Healthcare

• People do not intend to cause harm• Incidents are rarely due to single errors and are often the

end product of multiple factors• Analyses of incidents : less focus on the individual and

more on the organisation• What does this tell us about ‘our’ system• Safety is everyone’s responsibility

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Errors and Harm

• Not all errors result in harm

• Not all harm is as the result of errors

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Rates of Error/Adverse Events in 7 international studies

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

Harvard (NY) Utah Australia New Zealand UK Canada Ethographicstudy

Retrospective Notes Review

Prospective Observational Study

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Impact of adverse events

Direct costs• Estimated cost of preventable adverse events in

the USA $10.1 billion dollars (Leape et al 1993) • Study in Utah and Colorado estimated the cost of

adverse events to be $159,245,000. • On average preventable drug events resulted in an

additional 4.6 days in length of stay• In England healthcare associated infections are

estimated to cost over £1 billion pounds a year

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Indirect costs

• Increased pain and discomfort • Lost earnings • Impact on work & social lives • Psychological trauma• Disability• Death• Impact on carers and families• At any one time 1.4 million people worldwide are

suffering from infections acquired in hospital

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Impact on Healthcare workers• Profound consequences• Shame • Guilt• Litigation & complaints• Anxiety• Loss of confidence• Impact on families & co-workers

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Why Trigger Tools?• Conventional approaches to quantifying

adverse events:– Voluntary Incident Reporting– Record Reviews– Observational databases

• 2000 The IHI Trigger Tool for Measuring Adverse Drug Events (ADE)

• This was based on the principle of Triggers

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Background• Trigger Tools focus on identifying

harm as opposed to errors

• By focusing on events experienced by patients it can help shift the culture from individual blame for errors.

• This can facilitate system redesign

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Global Trigger Tool• IHI Global Trigger Tool (GTT) goes beyond

medications

• Focus is on adverse events related to delivery of care (acts of commission)

• Rather than issues related to substandard care (omissions)

• Omissions often leads to judgment and individual blame rather than focus on system solutions.

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What does the tool tell you?

• Adverse Event Rate per 1000 patient days40 per 1000 pt days = 4 per 100 pt days1 per 25 daysIn a 25 bed ward = That is 1 patients harmed every day

• 25 per 1000 bed days = 2.5 per 100 pt daysIn a 25 bed ward = 2.5 incidents in 4 daysThat is a patient is harmed every other day

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What else can it tell us?• 1000 Lives Campaign Reporting Summary

Spreadsheet for the Trigger Tool

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Most frequent:G1 Lack of Early Warning score or score requiring responseG4 Readmission within 30 daysG7 Complication of procedure or treatmentG8 Transfer to higher level of care L4 Rising urea or creatinine

Frequency of Triggers 2005 -2007

0

20

40

60

80

100

120

140

Series1

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Most frequent:G7 Complication of procedure or treatmentG4 Readmission within 30 daysG2 Patient FallL12 Wound Infection

Adverse Event Triggers 2005 - 2007

0

2

4

6

8

10

12

14

16

18

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G General care S Surgical care I Intensive care M Medication L Lab tests

Events by Module 2005 - 2007

0

5

10

15

20

25

30

35

GTOTAL

STOTAL

ITOTAL

MTOTAL

LTOTAL

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Degree of Harm Jan 2005 - July 2006

0

1

2

3

4

5

6

7

8

9

10

I

H

G

F

E

E Contributed to or resulted in temporary harm to the patient & required interventionF Contributed to or resulted in temporary harm to the patient & required initial or prolonged hospitalisationG Contributed to or resulted in permanent patient harm H Required intervention to sustain lifeI Contributed to the patients death

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Case Note Reviews – Examples of Learning

• The amount of missing

information in records:• Prescription sheets

• Nursing records

• TPR charts

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Case Note Reviews – Examples of Learning

Standard of documentation:

• Patient not documented

as discharged • Illegible hand writing• Events not documented

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Trigger Tools - Summary• Powerful Tool for identifying events/harm to

patients• Time consuming• Form is not intuitive BUT has been adapted • Important to keep a record of the events• The Global Tool is designed for adults • Other tools available e.g. Adverse Drug Events,

ITU, Neonatal ICU, Outpatients, Peri-operative, Mental health

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Next Steps?

Any Questions?