Abstract Objectives: To develop and evaluate a more robust approach for the detection of adverse events in hospital patients using an enhanced Institute for Healthcare Improvement Global Trigger Tool methodology. Methods: We refined the Institute for Healthcare Improvement Global Trigger methodology using a 2-stage review approach with initial review by 4 clinicians followed by a second review by 2 physicians and then a consensus process. We used a 2-step process for evaluation, and all 6 reviewers participated in both training and, then, testing phase. We measured agreement between all reviewers for the presence and severity of adverse events during the training and testing phase using percent agreement and kappa. Results: This study used 15 training records containing 22 adverse events and 50 testing records containing 49 adverse events. Initially, the 6 reviewer's agreement with the training records ranged from 38.5% to 76.9%, with kappa ranges from -0.077 to 0.512. After training, percent agreement with the testing records ranged from 66.7% to 93.9%, with kappa values ranging from 0.164 to 0.703. All levels of improvement in reviewer agreement were statistically significant, at the 0.05 level or better, except one of the nonphysician reviewers, whose improvement (71.7% to 83.5%) was significant at only the 0.06 level. Conclusions: We have developed a robust trigger methodology for detection of adverse events in hospital patients using a retrospective record review approach with a 2-stage review process. This approach has shown the capability, when used with trained reviewers, to achieve high levels of agreement on the presence and severity of adverse events.

Intensive care is advanced and highly technical, and it is essential that, despite this, patient care remains safe and of high quality. Adverse events (AEs) are supposed to be reported to internal quality control systems by health-care providers, but many are never reported. Patients on the intensive care unit (ICU) are at special risk for AEs. Our aim was to identify the incidence and characteristics of AEs in patients who died on the ICU during a 2-year period.A structured record review according to the Global Trigger Tool (GTT) was used to review charts from patients cared for at the ICU of a middle-sized Swedish hospital during 2007 and 2008 and who died during or immediately after ICU care. All identified AEs were scored according to severity and preventability.We reviewed 128 records, and 41 different AEs were identified in 25 patients (19.5%). Health care-associated infections, hypoglycaemia, pressure sores and procedural complications were the most common harmful events. Twenty two (54%) of the AEs were classified as being avoidable. Two of the 41 AEs were reported as complications according to the Swedish Intensive Care Registry, and one AE had been reported in the internal AE-reporting system.Almost one fifth of the patients who died on the ICU were subjected to harmful events. GTT has the advantage of identifying more patient injuries caused by AEs than the traditional AE-reporting systems used on many ICUs.

To investigate adverse events (AEs) at baseline in a Chinese general hospital using the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) and discuss the feasibility of this tool to detect AEs in China. A total of 10 inpatient records from the hospital were sampled randomly half a month in 2014. The records were reviewed to identify AEs according to the second edition of the IHI GTT for measuring AEs. Triggers and AEs were analyzed using Microsoft Excel 2007. Statistical analyses were performed using IBM SPSS software, version 19.0. A review of 240 patient records identified 51.0% (26/51) triggers in the worksheet, and 33.3% (17/51) were associated with AEs. A total of 70 AEs were identified in 54 patients, including 65.7% (46/70) category E AEs, which represent temporary harm requiring intervention, and 34.3% (24/70) category F AEs, which represent temporary harm requiring initial or prolonged hospitalization. The average rate of AEs per 1000 patient-days was 32.1 卤 20.9. The average rate of AEs per 100 admissions was 29.2 卤 16.1. The average rate of admissions with an AE was 22.5% 卤 13.9%. The most significant characteristic of patients with AEs was longer hospital stay. More than one fifth of adult inpatients in the current study experienced at least one AE resulting in temporary harm, most commonly caused by surgical operations and medication. With some modifications, the IHI GTT is a feasible and effective tool for detecting the overall status of AEs in a Chinese hospital.

Traditional medicine has been used worldwide in recent decades. The aim of this study was to determine the incidence of adverse events (AEs) in traditional medicine hospitals and investigate patient and health-care utilization factors associated with AE occurrence. A 2-stage review of 1152 randomly sampled charts in 2 teaching Korean traditional medicine hospitals was conducted. Three physicians and a quality improvement specialist identified AE occurrence, severity, and preventability using the Global Trigger Tool (Appendix 1, Supplemental Digital Content, http://links.lww.com/JPS/A19). Two traditional Korean medicine professors validated the findings. Logistic regression analysis was performed to determine factors associated with AE occurrence. One hundred twenty-two admissions (10.6%) had at least one AE (7.39 events per 1000 patient days and 14.5 events per 100 admissions). Among 167 AEs, 73.7% were mild and 70.7% were judged preventable. Procedure-related AEs were most common. After considering other patient and health-care utilization characteristics, factors associated with AE occurrence were altered mental status on admission (OR, 3.86; 95% confidence interval [CI], 1.20-12.44), use of various traditional medicine therapies (OR, 1.69; 95% CI, 1.32-2.15), length of stay (OR, 1.02; 95% CI, 1.01-1.03), and number of unique triggers (OR, 6.35; 95% CI, 4.54-8.89). Approximately 11% of inpatients in traditional medicine hospitals experienced AEs. Because patients have a higher risk of AEs, special attention should be paid to those with altered mental status on admission, receiving various traditional medicine therapies, staying for a longer period, and having various positive triggers.

Abstract In 2005, our organization set a goal of zero preventable deaths by 2010--notionally a sound goal but extremely challenging to measure, monitor and evaluate. The development of an interdisciplinary Death and Adverse Event Review process has provided a measure and framework for action to decrease adverse events (AEs) that cause harm. Death and Adverse Event Review is a formal process in which trained reviewers consider patient deaths using a modified Global Trigger Tool to establish the presence of AEs or quality of care issues that may have potentially led to death or harm. When identified, these charts go to second-level review by a physician/interdisciplinary team to determine recommendations for actions to prevent future reoccurrences. Data have provided trending of system influences to patient safety. In 2008-2009, 1,817 deaths were reviewed and AE rates of 12.1% and 16.3% were identified. There were 422 AEs and 114 quality of care issues identified for follow-up. Of the 4.7% and 6.3% referred to the physician/interdisciplinary team for secondary review, 2.3% and 2.6% resulted in recommendations for improvement. In addition to local improvements, many system improvements have occurred as a result of the review, such as proposed minimum standards for physician documentation; a formal review of post-operative guidelines for patients with sleep apnea; and a working group to review nursing documentation, communication/follow-up of vital signs, fluid balance and pain management. The Death and Adverse Event Review process provides a new critical level of detail that supports continuous improvements to our care processes and ongoing progress toward our goal of zero preventable deaths.

Patients decide to take antibiotics themselves in 21% of cases of acute respiratory viral infections, influenza and acute respiratory infections [1]. The main factor of drug purchase at a pharmacy is pharmacist's recommendation. In 14% of cases of purchase of antibiotics, patients describe the symptoms and do not name a specific drug. This provides opportunity for drug selection at a pharmacy [2]. In these circumstances the role of pharmacists in ensuring the rational use of antimicrobial agents increases significantly.To evaluate the knowledge of pharmacists about antibiotics for systemic use.Pharmacoepidemiological study was based on surveying pharmaceutical workers using a questionnaire. The questionnaire included 2 groups of questions: general questions aimed at identifying the socio-demographic characteristics of respondents (gender, age) and professional status (level of qualification, work experience), as well as specific questions aimed at identifying perceptions and knowledge of respondents about the studied group of drugs (range of used drugs, the factors determining and limiting the choice of drug, properties of individual drugs, etc.). The study involved 182 pharmaceutical workers at the age of 20 to 52 years. When processing the received data, we used Microsoft Excel and BioStat, and methods of nonparametric statistics (χ2-test). The survey was conducted anonymously, informed consent of the participants was not required. According to the recommendations of Ethical Committee of Saratov State Medical University n.a. V.I. Razumovsky (protocol No. 8 from 01.04.2014) the study is consistent with the basics of medical ethics.Interviewed pharmaceutical workers were mostly women (97%) with secondary pharmaceutical education (84%). The average age of the respondents was 27.0 ± 0.5 years. The work experience of the respondents ranged from 0.5 to 34 years (average experience 5.64 ± 0.41 years).Almost all pharmacists (97%) reported that they dispense antimicrobial drugs every day and consult patients about the choice and characteristics of antibiotic (99.5%). However, only 20% of the respondents indicated that they refuse to recommend antibiotics to the pharmacy visitors and send them to the doctor. Most often pharmaceutical employees recommended azithromycin (45%), amoxicillin in combination with clavulanic acid (41%), amoxicillin (26%). According to respondents, the choice of recommended antibiotic mostly depends (score on a scale of 1-5) on pharmacological characteristics of the drug: the effectiveness (of 4.66 ± 0.04) and safety (4.16 ± 0.07). Thus, pharmaceutical specialist should be knowledgeable about characteristics of antimicrobial agents to conduct proper consultation.According to the results of self-assessment of respondents' knowledge about antibiotics it is at an average level. 36.3% of respondents state that they are familiar with the range and features of most of the drugs. 41.8% of professionals are familiar with the range of the most popular drugs and their main features. Only 16.5% of respondents assess their knowledge about antibiotics at the highest level, indicating that they are fully familiar with the range and features of the drugs.Aiming at identifying knowledge about the side effects of antibiotics pharmacists were asked to compare the most commonly prescribed drugs and their respective side effects, to position the drugs and groups of drugs in the range according to the degree of toxicity and to indicate which antibiotics can be used during pregnancy. Knowledge of pharmaceutical workers is mainly limited to the perceptions of non-specific side reactions that can occur when taking any antibiotic (dyspepsia, allergic reactions, headache, candidiasis). 54.9% of respondents rightly pointed out nonspecific reactions for all 7 mentioned drug, for individual drugs the proportion of correct answers varied from 65,4% (linezolid) to 81,3% (amoxicillin+clavulanic acid). The analysis revealed no relationship between respondents' answers and their qualifications (χ2 = 0,053; p = 0,818), work experience (χ2 = 6,956; p = 0,096) and self-assessed knowledge about antimicrobial drugs (χ2 = 1,272; p = 1,000). There were no respondents who correctly reported specific adverse reactions (hearing disorder for azithromycin, hemopoiesis oppression for linezolid, etc.) for each antibiotic. The proportion of correct answers ranged from 6,0% for the combination amoxicillin+clavulanic acid to 43,4% for cefixime and doxycycline. The relationship between knowledge of respondents and frequency of recommendations of the same group of drugs could not be determined.Pharmacists assume that the safest antibiotics are macrolides (average rank place of 2,99 ± 0,15 of 8), cephalosporins (3,12 ± 0,15) and penicillins (3,38 ± 0,22), the most toxic are tetracyclines (5,61 ± 0,17). It should be noted that average rank places are quite similar, which means serious differences of opinion between the specialists. When assessing the toxicity of individual drugs a combination of amoxicillin+clavulanic acid (average rank place of 2,92 ± 0,29 of 15) and ampicillin (of 4,88 ± 0,36) were considered as the safest, the most toxic were tetracycline (10,13 ± 0,30) and gentamicin (10,14 ± 0,33). These perceptions are generally consistent with the views on the safety of antibiotics in outpatient practice [3].Half of the respondents (51,1%) correctly identified the antibiotics that can be used during pregnancy (FDA category B). 45,1% of respondents said that no antibiotics can be used during pregnancy. Only 2,7% of respondents named drugs contraindicated during pregnancy (category C and D) - gentamicin, doxycycline, ciprofloxacin.The study identified gaps in the knowledge of pharmacists about the safety of antimicrobial agents. Views of professionals about antibiotics are mostly consistent with current data about the properties of drugs. However, detailed analysis shows that such views are not supported by clear knowledge of the properties of each drug and are mostly intuitive. In terms of the prevalence of self-medication with antibiotics and OTC dispensing of antimicrobial drugs it is necessary to improve the professional knowledge of pharmaceutical workers on antibiotics for systemic use.

A high-quality health system should deliver care that is free from harm. Few large-scale studies of adverse events have been undertaken in children's healthcare internationally, and none in Australia. The aim of this study is to measure the frequency and types of adverse events encountered in Australian paediatric care in a range of healthcare settings.A form of retrospective medical record review, the Institute of Healthcare Improvement's Global Trigger Tool, will be modified to collect data. Records of children aged <16鈥厃ears managed during 2012 and 2013 will be reviewed. We aim to review 6000-8000 records from a sample of healthcare practices (hospitals, general practices and specialists).Human Research Ethics Committee approvals have been received from the Sydney Children's Hospital Network, Children's Health Queensland Hospital and Health Service, and the Women's and Children's Hospital Network in South Australia. An application is under review with the Royal Australian College of General Practitioners. The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers.

To describe the level, preventability and categories of adverse events (AEs) identified by medical record review using the Global Trigger Tool (GTT). To estimate when the AE occurred in the course of the hospital stay and to compare voluntary AE reporting with medical record reviewing.Two-stage retrospective record review.650-bed university hospital.20 randomly selected medical records were reviewed every month from 2009 to 2012.AE/1000 patient-days. Proportion of AEs found by GTT found also in the voluntary reporting system. AE categorisation. Description of when during hospital stay AEs occur.A total of 271 AEs were detected in the 960 medical records reviewed, corresponding to 33.2 AEs/1000 patient-days or 20.5% of the patients. Of the AEs, 6.3% were reported in the voluntary AE reporting system. Hospital-acquired infections were the most common AE category. The AEs occurred and were detected during the hospital stay in 65.5% of cases; the rest occurred or were detected within 30鈥卍ays before or after the hospital stay. The AE usually occurred early during the hospital stay, and the hospital stay was 5鈥卍ays longer on average for patients with an AE.Record reviewing identified AEs to a much larger extent than voluntary AE reporting. Healthcare organisations should consider using a portfolio of tools to gain a comprehensive picture of AEs. Substantial costs could be saved if AEs were prevented.

OBJECTIVE: To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system. STUDY SETTING: Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay 鈮3 days were reviewed. STUDY DESIGN: We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems. DATA COLLECTION: Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs). PRINCIPAL FINDINGS: Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with 鈮1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs. CONCLUSIONS: AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

Abstract OBJECTIVE: Determine the degree of congruence between several measures of adverse events. DESIGN: Cross-sectional study to assess frequency and type of adverse events identified using a variety of methods. SETTING: Mayo Clinic Rochester hospitals. PARTICIPANTS: All inpatients discharged in 2005 (n = 60 599). INTERVENTIONS: Adverse events were identified through multiple methods: (i) Agency for Healthcare Research and Quality-defined patient safety indicators (PSIs) using ICD-9 diagnosis codes from administrative discharge abstracts, (ii) provider-reported events, and (iii) Institute for Healthcare Improvement Global Trigger Tool with physician confirmation. PSIs were adjusted to exclude patient conditions present at admission. MAIN OUTCOME MEASURE: Agreement of identification between methods. RESULTS: About 4% (2401) of hospital discharges had an adverse event identified by at least one method. Around 38% (922) of identified events were provider-reported events. Nearly 43% of provider-reported adverse events were skin integrity events, 23% medication events, 21% falls, 1.8% equipment events and 37% miscellaneous events. Patients with adverse events identified by one method were not usually identified using another method. Only 97 (6.2%) of hospitalizations with a PSI also had a provider-reported event and only 10.5% of provider-reported events had a PSI. CONCLUSIONS: Different detection methods identified different adverse events. Findings are consistent with studies that recommend combining approaches to measure patient safety for internal quality improvement. Potential reported adverse event inconsistencies, low association with documented harm and reporting differences across organizations, however, raise concerns about using these patient safety measures for public reporting and organizational performance comparison.

To assess the frequency, severity, and preventability of adverse events (AEs) detected using the Global Trigger Tool (GTT) in an acute geriatric hospital.DesignA 6-year retrospective study.SettingAn urban Spanish acute geriatric teaching hospital of 200 beds.ParticipantsTen randomly selected clinical records were chosen every fortnight from January 2007 to December 2012 (1,440 records, 240 per year).MeasurementsTriggers, AEs, Index of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) categories of severity, and Likert scale to evaluate the preventability of AEs.ResultsFour hundred twenty-four AEs (categories E to I of the NCC MERP Index) were identified in 335 of the 1,440 individuals scrutinized, which corresponded to 29.4 physical injuries per 100 admissions (95% confidence interval (CI) = 25.7–34.7). Of these, 351 (91.7%) occurred 3 or more days after admission; 279 harms (65.8%) were preventable. Significant decreases in the rate of harms per 1,000 patient-days (21.8 vs 27.1, relative risk (RR) = 0.77, 95% CI 0.66–0.91, P = .02) and in high-severity events (categories F to I) (11/720 clinical records in 2011–2012 vs 23/720 clinical records in 2007–2009) (RR = 0.48, 95% CI = 0.24–0.96, P = .04) were observed during the second half of the study from the first. The number needed to alert was 7.8.ConclusionThe frequency and severity of AEs decreased during the period of study. Factors possibly contributing to the decrease in AEs include new beds with variable height, pressure ulcer prevention, introduction of clinical electronic records, staff training on hand washing, surgical check list, correct patient identification, and Agency for Healthcare Research and Quality surveys on patient safety culture.

The tool used in this study is valid, useful and reproducible for the detection of AE. It also serves to determine rates of injury and to observe their progression over time. A high frequency of both AE and preventable events were observed in this study.

/st> The aim of this study was to evaluate patient safety levels in Palestinian hospitals and to provide guidance for policymakers involved in safety improvement efforts./st> Retrospective review of hospitalized patient records using the Global Trigger Tool./st> Two large hospitals in Palestine: a referral teaching hospital and a nonprofit, non-governmental hospital./st> A total of 640 random records of discharged patients were reviewed by experienced nurses and physicians from the selected hospitals./st> Assessment of adverse events./st> Prevalence of adverse events, their preventability and harm category. Descriptive statistics and Cohen kappa coefficients were calculated./st> One out of seven patients (91 [14.2%]) suffered harm. Fifty-four (59.3%) of these events were preventable; 64 (70.4%) resulted in temporary harm, requiring prolonged hospitalization. Good reliability was achieved among the independent reviewers in identifying adverse events. The Global Trigger Tool showed that adverse events in Palestinian hospitals likely occur at a rate of 20 times higher than previously reported. Although reviewers reported that detecting adverse events was feasible, we identified conditions suggesting that the tool may be challenging to use in daily practice./st> One out of seven patients suffers harm in Palestinian hospitals. Compromised safety represents serious problems for patients, hospitals and governments and should be a high priority public health issue. We argue that direct interventions should be launched immediately to improve safety. Additional costs associated with combating adverse events should be taken into consideration, especially in regions with limited resources, as in Palestine.

Background The Institute for Healthcare Improvement encourages use of the Global Trigger Tool to objectively determine and monitor adverse events (AEs). Setting Baylor Health Care System (BHCS) is an integrated healthcare delivery system in North Texas. The Global Trigger Tool was applied to BHCS's eight general acute care hospitals, two inpatient cardiovascular hospitals and two rehabilitation/long-term acute care hospitals. Strategy Data were collected from a monthly random sample of charts for each facility for patients discharged between 1 July 2006 and 30 June 2007 by external professional nurse auditors using an MS Access Tool developed for this initiative. In addition to the data elements recommended by Institute for Healthcare Improvement, BHCS developed fields to permit further characterisation of AEs to identify learning opportunities. A structured narrative description of each identified AE facilitated text mining to further characterise AEs. Initial findings Based on this sample, AE rates were found to be 68.1 per 1000 patient days, or 50.8 per 100 encounters, and 39.8% of admissions were found to have ≥1 AE. Of all AEs identified, 61.2% were hospital-acquired, 10.1% of which were associated with a National Coordinating Council – Medical Error Reporting and Prevention harm score of “H or I” (near death or death). Future Direction To enhance learning opportunities and guide quality improvement, BHCS collected data—such as preventability and AE source—to characterise the nature of AEs. Data are provided regularly to hospital teams to direct quality initiatives, moving from a general focus on reducing AEs to more specific programmes based on patterns of harm and preventability.

Abstract OBJECTIVES: To describe how adverse event (AE) rates were monitored and estimated nationally across all Norwegian hospitals from 2010 to 2013, and how they developed during the monitoring period. Monitoring was based on medical record review with Global Trigger Tool (GTT). SETTING: All publicly and privately owned hospitals were mandated to review randomly selected medical records to monitor AE rates. The initiative was part of the Norwegian patient safety campaign, launched by the Norwegian Ministry of Health and Care Services. It started in January 2011 and lasted until December 2013. 2010 was the baseline for the review. One of the main aims of the campaign was to reduce patient harm. METHOD: To standardise the medical record reviews in all hospitals, GTT was chosen as a standard method. GTT teams from all hospitals reviewed 4061851 medical records randomly selected from 26124961957 discharges from 2010 to 2013. Data were plotted in time series for local measurement and national AE rates were estimated, plotted and monitored. RESULTS: AE rates were estimated and published nationally from 2010 to 2013. Estimated AE rates in severity categories E-I decreased significantly from 16.1% in 2011 to 13.0% in 2013 (-3.1% (95% CI -5.2% to -1.1%)). CONCLUSIONS: Monitoring estimated AE rates emerges as a potential element in national systems for patient safety. Estimated AE rates in the category of least severity decreased significantly during the first 261years of the monitoring. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

To identify the prevalence, preventability, and severity of adverse drug events in randomly selected adult hospital inpatients, and to study the association between adverse drug events and patient‐specific factors.

Abstract BACKGROUND: A multi-method strategy has been proposed to understand and improve the safety of primary care. The trigger tool is a relatively new method that has shown promise in American and secondary healthcare settings. It involves the focused review of a random sample of patient records using a series of "triggers" that alert reviewers to potential errors and previously undetected adverse events. AIM: To develop and test a global trigger tool to detect errors and adverse events in primary-care records. METHOD: Trigger tool development was informed by previous research and content validated by expert opinion. The tool was applied by trained reviewers who worked in pairs to conduct focused audits of 100 randomly selected electronic patient records in each of five urban general practices in central Scotland. RESULTS: Review of 500 records revealed 2251 consultations and 730 triggers. An adverse event was found in 47 records (9.4%), indicating that harm occurred at a rate of one event per 48 consultations. Of these, 27 were judged to be preventable (42%). A further 17 records (3.4%) contained evidence of a potential adverse event. Harm severity was low to moderate for most patients (82.9%). Error and harm rates were higher in those aged > or =60 years, and most were medication-related (59%). CONCLUSIONS: The trigger tool was successful in identifying undetected patient harm in primary-care records and may be the most reliable method for achieving this. However, the feasibility of its routine application is open to question. The tool may have greater utility as a research rather than an audit technique. Further testing in larger, representative study samples is required.

Abstract 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.

Background: Systems to identify risks and adverse events (AEs) in Australia are limited. This study aims to explore whether general practice records contain information on AEs, and to conduct a pilot study on the type and frequency of AEs in general practice in Australia, using a global trigger tool (GTT). Methods: Five practices were recruited and consented to collect data. Practice nurses were trained to collect data at their practices. Records from randomly sampled patients aged 75 years or older were reviewed. Results: A total of 428 patient records were reviewed. A total of 44 AEs were detected in 41 records. The percentage of patients with an AE was 9.6%. Most low preventability AEs (21/29) were medication incidents. Discussion: The study found that significant levels of information about AEs exist in general practice medical records and rates of harm are broadly in line with a similar study in Scotland.

目的验证全面触发工具用于检测药品不良事件的可行性。方法利用临床药学管理系统（2．1）随机抽取本院2014年10-12月500份住院患者病历进行回顾性分析，评价病历记录中可能存在的药品不良事件。结果在调查的500份住院病历中，39项触发器有25项触发器显阳性，触发器阳性频次为459次。其中抗过敏应用药物项（编号：33）触发频次最多，71次，占15．5％。确定药品不良事件77次，涉及53例患者，ADE检出率为16．8％（77／459）。阳性预测值以血钾异常项（编号：7、8）较其他高，分别占34．8％和30．0％。不良事件伤害分级集中在“轻微伤害”与“中度伤害”级别。结论全面触发工具在防范药品不良事件方面具有积极作用，但尚待完善。

目的采用全面触发工具（GT-F）建立儿童住院患者药品不良事件（ADE）的主动监测方法，评价住院患儿的ADE发生情况。方法用专家咨询法建立儿童ADE触发器，采用等距随机抽样方法抽取本院2014年10月至2015年9月住院患儿9-3档病历600份，按GTT法进行回顾性病历审查。对触发器阳性所涉及情况进一步审查以确定或排除ADE，审查中发现的无触发器阳性但确定发生的ADE一并记录。所有ADE进行严重程度分级、类型分布及相关药物分析，计算ADE检出率及触发器阳性预测值（PPV）等。结果最终纳入587例病历，共检出119例患儿共计159例次ADE。GTT检出105例患儿共计120例次ADE，检出率17．9％（105／587），无触发器阳性但确定为ADE的39例次。建立的36项触发器，实际应用中有26项呈阳性（72％）；触发器总阳性频次905次，检出ADE的有143次，触发器PPV15．8％（143／905）。159例次ADE中暂时性伤害占98．7％（E级77．4％、F级20．8％），最常累及胃肠系统，相关药物以抗菌药物为主（36．9％）。结论GTF对儿童ADE的监测及评价具有积极作用，但尚需进一步改进。

ABSTRACT Most studies of healthcare complications identify surgery as a major contributor to the overall burden of complicated care that leads to injury or death. Indeed, surgical adverse events account for one-half to three-quarters of all adverse events in these studies. Despite the intensive current focus on improving medical quality and safety, only a minority of quality improvement efforts are focused on surgery. This study reports on the development and testing of a Trigger Tool to detect adverse events among patients undergoing inpatient surgery. Rather than relying on traditional voluntary reporting for safety outcome measures such as incident reports, surgical peer review, or morbidity and mortality conferences, the Institute for Healthcare Improvement (IHI) has employed a new method for the detection of surgical adverse events (SAEs). This approach, commonly referred to as the "Trigger Tool", identifies adverse events using a form of retrospective record review that has been developed and implemented in many areas of care. During a 12-month IHI Perioperative Safety Collaborative, 11 hospitals voluntarily submitted data from surgical inpatient record reviews. In 854 patients, 138 SAEs were detected in 125 records for a rate of 16 SAEs per 100 patients or 14.6% of patients; 61 (44%) of these events contributed to increased length of stay or readmission and 12 (8.7%) events required life-saving intervention or resulted in permanent harm or death. Hospital review teams reported verbally that most of the events identified during the Trigger Tool review process had not been detected or reported via any other existing mechanism. The IHI Surgical Trigger Tool may offer a practical, easy-to-use approach to detecting safety problems in patients undergoing surgery; it can be the basis not only for estimating the frequency of adverse events in an organisation, but also determining the impact of interventions that focus on reducing adverse events in surgical patients.

Abstract OBJECTIVES: Currently there are few practical methods to identify and measure harm to hospitalized children. Patients in NICUs are at high risk and warrant a detailed assessment of harm to guide patient safety efforts. The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool. METHODS: A NICU-focused trigger tool for adverse event detection was developed and tested. Fifty patients from each site with a minimum 2-day NICU stay were randomly selected. All adverse events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger, and the entire tool, was evaluated for positive predictive value. Study chart reviewers, in aggregate, identified 88.0% of all potential triggers and 92.4% of all potential adverse events. RESULTS: Review of 749 randomly selected charts from 15 NICUs revealed 2218 triggers or 2.96 per patient, and 554 unique adverse events or 0.74 per patient. The positive predictive value of the trigger tool was 0.38. Adverse event rates were higher for patients <28 weeks' gestation and <1500 g birth weight. Fifty-six percent of all adverse events were deemed preventable; 16% could have been identified earlier, and 6% could have been mitigated more effectively. Only 8% of adverse events were identified in existing hospital-based occurrence reports. The most common adverse events identified were nosocomial infections, catheter infiltrates, and abnormal cranial imaging. CONCLUSIONS: Adverse event rates in the NICU setting are substantially higher than previously described. Many adverse events resulted in permanent harm and the majority were classified as preventable. Only 8% were identified using traditional voluntary reporting methods. Our NICU-focused trigger tool appears efficient and effective at identifying adverse events.

Background The association between measurements of the patient safety culture and the ???true??? patient safety has been insufficiently documented, and the validity of the tools used for the measurements has been questioned. This study explored associations between the patient safety culture and adverse events, and evaluated the validity of the tools. Methods In 2008/2009, a survey on patient safety culture was performed with Hospital Survey on Patient Safety Culture (HSOPSC) in two medical departments in two geographically separated hospitals of Innlandet Hospital Trust. Later, a retrospective analysis of adverse events during the same period was performed with the Global Trigger Tool (GTT). The safety culture and adverse events were compared between the departments. Results 185 employees participated in the study, and 272 patient records were analysed. The HSOPSC scores were lower and adverse events less prevalent in department 1 than in department 2. In departments 1 and 2 the mean HSOPSC scores (SD) were at the unit level 3.62 (0.42) and 3.90 (0.37) (p???&lt;???0.001), and at the hospital level 3.35 (1.53) and 3.67 (0.53) (ns, p???=???0.19) respectively. The proportion of records with adverse events were 10/135 (7%) and 28/137 (20%) (p???=???0.003) respectively. Conclusions There was an inverse association between the patient safety culture and adverse events. Until the criterion validity of the tools for measuring patient safety culture and tracking of adverse events have been further evaluated, measurement of patient safety culture could not be used as a proxy for the ???true??? safety.

La prevención de caídas de pacientes es una tarea importante en las Unidades geriátricas con una potencial reducción de costes y da09os, algunas medidas como la bajada de la altura de la cama mostraron una reducción significativa de las caídas.

No randomized trials have examined the effect of contact precautions or universal glove and gown use on adverse events. We assessed if wearing gloves and gowns during all patient contact in the intensive care unit (ICU) changes adverse event rates.From January 2012 to October 2012, intervention ICUs of the 20-site Benefits of Universal Gloving and Gowning cluster randomized trial required that healthcare workers use gloves and gowns for all patient contact. We randomly sampled 1800 medical records of adult patients not colonized with antibiotic-resistant bacteria and reviewed them for adverse events using the Institute for Healthcare Improvement Global Trigger Tool.Four hundred forty-seven patients (24.8%) had 1 or more ICU adverse events. Adverse events were not associated with universal glove and gown use (incidence rate ratio [IRR], 0.81; 95% confidence interval [CI], .48-1.36). This did not change with adjustment for ICU type, severity of illness, academic hospital status, and ICU size, (IRR, 0.91; 95% CI, .59-1.42; P = .68). Rates of infectious adverse events also did not differ after adjusting for the same factors (IRR, 0.75; 95% CI, .47-1.21; P = .24).In ICUs where healthcare workers donned gloves and gowns for all patient contact, patients were no more likely to experience adverse events than in control ICUs. Concerns of adverse events resulting from universal glove and gown use were not supported. Similar considerations may be appropriate regarding use of contact precautions.NCT0131821.

Abstract OBJECTIVES: Adverse events (AEs) are unintended physical injuries resulting from or contributed to by medical or surgical care. We determined the frequency and type of AEs before, during, and after hospital admission. METHODS: We conducted a cohort study of 296 adult hospital patients. We used the standardized Institute for Healthcare Improvement Global Trigger Tool for Measuring Adverse Events to review the medical records of the hospital patients for occurrence, timing relative to hospital admission, severity, and preventability of AEs. We also identified the primary physiologic system affected by the AE. RESULTS: Among 296 patients, we identified 338 AEs. AEs occurred with similar frequency before (n = 148; 43.8%) and during hospital admission (n = 162; 47.9%). Fewer AEs occurred after discharge (n = 28; 8.3%). Half of all AEs (n = 169; 50.0%) were severe, whereas 47.9% (n = 162) were preventable. CONCLUSIONS: AEs occur with similar frequency before and during hospitalization and may contribute more to hospital admissions than previously recognized. These findings suggest that efforts to improve patient safety should include outpatient settings in addition to the more commonly targeted acute care settings.

Abstract OBJECTIVE: The aim of this study was to determine the impact of all-cause inpatient harms on hospital finances and patient clinical outcomes. RESEARCH DESIGN: A retrospective analysis of inpatient harm from 24 hospitals in a large multistate health system was conducted during 2009 to 2012 using the Institute of Healthcare Improvement Global Trigger Tool for Measuring Adverse Events. Inpatient harms were detected and categorized into harm (F-I), temporary harm (E), and no harm. RESULTS: Of the 21,007 inpatients in this study, 15,610 (74.3%) experienced no harm, 2818 (13.4%) experienced temporary harm, and 2579 (12.3%) experienced harm. A patient with harm was estimated to have higher total cost ($4617 [95% confidence interval (CI), $4364 to 4871]), higher variable cost ($1774 [95% CI, $1648 to $1900]), lower contribution margin (-$1112 [95% CI, -$1378 to -$847]), longer length of stay (2.6 d [95% CI, 2.5 to 2.8]), higher mortality probability (59%; odds ratio, 1.4 [95% CI, 1.0 to 2.0]), and higher 30-day readmission probability (74.4%; odds ratio, 2.9 [95% CI, 2.6 to 3.2]). A patient with temporary harm was estimated to have higher total cost ($2187 [95% CI, $2008 to $2366]), higher variable cost ($800 [95% CI, $709 to $892]), lower contribution margin (-$669 [95% CI, -$891 to -$446]), longer length of stay (1.3 d [95% CI, 1.2 to 1.4]), mortality probability not statistically different, and higher 30-day readmission probability (54.6%; odds ratio, 1.2 [95% CI, 1.1 to 1.4]). Total health system reduction of harm was associated with a decrease of $108 million in total cost, $48 million in variable cost, an increase of contribution margin by $18 million, and savings of 60,000 inpatient care days. CONCLUSIONS: This all-cause harm safety study indicates that inpatient harm has negative financial outcomes for hospitals and negative clinical outcomes for patients.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

We have increased the adverse events reporting due the inclusion of the reporting systems and a clinical risk manager working a full time, with a clearer picture of the types of adverse events with an integration of different data and reporting systems, and a better approach to improvement, monitoring and review of the processes. The nature of the sources in the reporting systems does not permit to know the ranking and real figures of the adverse events, and it is necessary to established priorities and to stagger the different reporting systems in the time and in function of the cost effectiveness measures. The reporting systems are the first step to analysis and is necessary to improve and mitigate the adverse events.

Medication-related harm can be detected using the adverse drug event (ADE) trigger tool and the medication module of the Global Trigger Tool (GTT) developed by the Institute for Healthcare Improvement (IHI). In recent years, there has been some controversy on the performance of this method. In addition, there are limited data on the performance of the medication module of the GTT as compared with the ADE trigger tool.To evaluate the performance of the ADE trigger tool and of the medication module of the GTT for identifying ADEs.The methodology of the IHI was used. A random sample of 20 adult admissions per month was selected over a 12-month period in a teaching hospital in Belgium. The ADE trigger tool was adapted to the Belgian setting and included 20 triggers. The positive predictive value (PPV) of each trigger was calculated, as well as the proportion of ADEs that would have been identified with the medication module of the GTT as compared with the ADE trigger tool.A total of 200 triggers and 62 ADEs were found, representing 26 ADEs/100 admissions. Nineteen ADEs (31%) were found spontaneously without the presence of a trigger. Three triggers never occurred. The PPVs of other triggers varied from 0 to 0.67, with half of them having PPVs less than 0.20. If we had used the medication triggers included in the GTT (n = 11), we would have identified 77% of total ADEs and 67% of preventable ADEs.Applying the trigger tool method proposed by the IHI to a Belgian hospital led to the identification of one ADE out of 4 admissions. To increase performance, refining the list of triggers in the ADE trigger tool and in the medication module of the GTT would be needed. Recording nontriggered events should be encouraged.

Abstract BACKGROUND: There 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. METHODS: We 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. RESULTS: Altogether, 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. CONCLUSIONS: More 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.

Monitoring patient safety is a challenging task. The lack of a golden standard has contributed to the recommendation and introduction of several methods. In 2000 the Danish Lung Cancer Registry (DLCR) was established to monitor the clinical management of lung cancer. In 2008 the Global Trigger Tool (GTT) was recommended in Denmark as a tool for the monitoring of patient safety. Ideally, the recommendation of a new tool should be preceded by a critical assessment of its added value.Data on complications related to lung cancer surgery from the Department of Cardiothoragic Surgery at Odense University Hospital were collected using the DLCR and the GTT in 2008. The capacity of these two methods to identify complications is compared and discussed.A total of 59 complications were registered in the DLCR, while 58 complications were registered using the GTT. The two methods were equally good at identifying complications, but the DLCR seemed to be borderline significantly better at detecting arrhythmia, while the GTT was significantly better at detecting "other events".Nearly half of the adverse events identified with the GTT were complications which were also registered by type in the DLCR. The two methods were almost equally good at identifying specific types of complications, but the GTT identified more "other events". The majority of these events were well-known to clinicians. The comparison illustrates why the implementation of new methods should be preceded by critical assessment. In this case, it is crucial to assess whether the current method should be modified by the addition of more patient safety indicators rather than by introducing a new method that partly duplicates existing data.

Abstract OBJECTIVES: An efficient and reliable process for measuring harm due to medical care is needed to advance pediatric patient safety. Several pediatric studies have assessed the use of trigger tools in varying inpatient environments. Using the Institute for Healthcare Improvement's adult-focused Global Trigger Tool as a model, we developed and pilot tested a trigger tool that would identify the most common causes of harm in pediatric inpatient environments. METHODS: After formal training, 6 academic children's hospitals used this novel pediatric trigger tool to review 100 randomly selected inpatient records per site from patients discharged during the month of February 2012. RESULTS: From the 600 patient charts evaluated, 240 harmful events ("harms") were identified, resulting in a rate of 40 harms per 100 patients admitted and 54.9 harms per 1000 patient days across the 6 hospitals. At least 1 harm was identified in 146 patients (24.3% of patients). Of the 240 total events, 108 (45.0%) were assessed to have been potentially or definitely preventable. The most common patient harms were intravenous catheter infiltrations/burns, respiratory distress, constipation, pain, and surgical complications. CONCLUSIONS: Consistent with earlier rates of all-cause harm in adult hospitals, harm occurs at high rates in hospitalized children. Availability and use of an all-cause harm identification tool will establish the epidemiology of harm and will provide a consistent approach to assessing the effect of interventions on harms in hospitalized children. Copyright 漏 2015 by the American Academy of Pediatrics.

This study aimed to examine the performance of the Global Trigger Tool and to investigate characteristics associated with the occurrence of adverse events (AEs).Retrospective medical record review.A tertiary teaching hospital, Korea.We employed two-stage review of a random sample of 630 charts for patients discharged between January and June 2011. Two quality improvement specialists reviewed the presence of AEs using 53 triggers developed by the Institute for Healthcare Improvement. Two physicians reviewed and validated the findings of adverse events. Positive predictive values for individual triggers were calculated. Logistic regression analysis was performed to determine factors associated with AEs.Of 629 patients, 45 (7%) experienced at least one AE during their hospitalization. Among the observed AEs, 61% were preventable. The frequent types of AEs were 'procedure-related' and 'medication-related'. Six triggers had positive predictive values of greater than 50.0%: 'health care-associated infection', 'any procedure complication', 'medication: other', 'return to surgery', 'occurrence of any operative complication' and 'intubation/reintubation'. Significant factors associated with the occurrence of AEs were length of stay (OR 1.13; 95% CI 1.07 to 1.20) and the number of triggers (OR 1.49; 95% CI 1.11 to 1.98).The Global Trigger Tool was useful for the detection of adverse events in a Korean hospital setting. Triggers with high positive predictive values should have priority for incorporation into routine screening systems. Furthermore, patients who stay longer in the hospital need to be closely monitored using triggers to improve patient safety.

Abstract Objective: To adapt the Global Trigger Tool (GTT) as a sustainable monitoring tool able to characterize adverse events (AEs) for organizational learning, within the context of limited resources. Methods: Baylor Health Care System (BHCS) expanded the AE data collected to include judgments of preventability, presence on admission, relation to care provided or not provided, and narrative descriptions. To reduce costs, we focused on patients with length of stay (LOS) of 3 days or more, suspecting greater likelihood they had experienced an AE; adapted the sample size and frequency of review; and used a single nurse reviewer followed by quality assurance review within the Office of Patient Safety. We compared AE rates in patients with LOS of less than 3 days versus 3 days or greater, assessed trigger yields and interrater reliability, and submitted identified AEs to each hospital for validation as event types targeted for reduction. Results: In 2008, 91% of identified AEs were in patients with LOS of 3 days or greater; there were 6.4 AEs per 100 discharges with LOS of less than 3 days versus 27.1 AEs per 100 discharges with LOS of 3 days or greater. Over 4 years, we reviewed 16,172 medical records; 14,184 had positive triggers, 17.1% of which were associated with an AE. Most AEs were identified via the "surgical" (36.3%) and "patient care" (36.0%) trigger modules. Reviewers showed fair to good agreement (魏 = 0.62), and hospital clinical leaders strongly agreed that the identified events were AEs. Conclusions: The GTT can be adapted to health-care organizations' goals and resource limitations. This flexibility was essential in crossing our organization's "value threshold."

Abstract BACKGROUND: Adverse drug events are considered determinants of patient safety and quality of care. OBJECTIVE: To assess the characteristics of adverse drug events in patients admitted to an intensive care unit and determine the impact of severity of illness and nursing workload on the prevalence of the events. METHODS: A cross-sectional survey based on retrospective analysis of a high-quality patient data management system for a university-based intensive care unit was used. The prevalence of adverse drug events was measured by using a validated global trigger tool adapted for the critical care environment. Severity was determined by using a validated algorithm. Disease severity and nursing workload were assessed by using validated scoring systems. An investigator blinded to the study and a panel of experts assessed putative serious adverse drug events for each drug taken. Characteristics of patients with and without adverse drug events were compared by using univariate and stepwise multivariate logistic regression. RESULTS: During 175 of 1009 intensive care unit days screened, 230 adverse drug events occurred in 79 patients. The most common events were hypoglycemia, prolonged activated partial thromboplastin time, and hypokalemia. Of the adverse events, 96% were classified as causing temporary harm and 4% as causing complications. Both mean severity of disease and nursing workload were significantly higher on days when 1 or more adverse drug events occurred. CONCLUSION: Adverse drug events were common in intensive care unit patients and were associated with illness severity and nursing workload.

Abstract Many patients are harmed as the result of healthcare. A retrospective structured record review is one way to identify adverse events (AEs). One such review approach is the global trigger tool (GTT), a consistent and well-developed method used to detect AEs. The GTT was originally intended to be used for measuring data over time within a single organisation. However, as the method spreads, it is likely that comparisons of GTT safety outcomes between hospitals will occur. To evaluate agreement in judgement of AEs between well-trained GTT teams from different hospitals. Five teams from five hospitals of different sizes in the southeast of Sweden conducted a retrospective review of patient records from a random sample of 50 admissions between October 2009 and May 2010. Inter-rater reliability between teams was assessed using descriptive and 魏 statistics. The five teams identified 42 different AEs altogether. The number of identified AEs differed between the teams, corresponding to a level of AEs ranging from 27.2 to 99.7 per 1000 hospital days. Pair-wise agreement for detection of AEs ranged from 88% to 96%, with weighted 魏 values between 0.26 and 0.77. Of the AEs, 29 (69%) were identified by only one team and not by the other four groups. Most AEs resulted in minor and transient harm, the most common being healthcare-associated infections. The level of agreement regarding the potential for prevention showed a large variation between the teams. The results do not encourage the use of the GTT for making comparisons between hospitals. The use of the GTT to this end would require substantial training to achieve better agreement across reviewer teams.

The trigger tool methodology uses clinical algorithms applied electronically to ‘flag’ medical records where adverse events (AEs) have most likely occurred. The authors sought to create surgical triggers to detect AEs in the ambulatory care setting.Four consecutive steps were used to develop ambulatory surgery triggers. First, the authors conducted a comprehensive literature review for surgical triggers. Second, a series of multidisciplinary focus groups (physicians, nurses, pharmacists and information technology specialists) provided user input on trigger selection. Third, a clinical advisory panel designed an initial set of 10 triggers. Finally, a three-phase Delphi process (surgical and trigger tool experts) evaluated and rated the suggested triggers.The authors designed an initial set of 10 surgical triggers including five global triggers (flagging medical records for the suspicion of any AE) and five AE-specific triggers (flagging medical records for the suspicion of specific AEs). Based on the Delphi rating of the trigger's utility for system-level interventions, the final triggers were: (1) emergency room visit(s) within 2161days from surgery; (2) unscheduled readmission within 3061days from surgery; (3) unscheduled procedure (interventional radiological, urological, dental, cardiac or gastroenterological) or reoperation within 3061days from surgery; (4) unplanned initial hospital length of stay more than 2461h; and (5) lower-extremity Doppler ultrasound order entry and ICD code for deep vein thrombosis or pulmonary embolus within 3061days from surgery.The authors therefore propose a systematic methodology to develop trigger tools that takes into consideration previously published work, end-user preferences and expert opinion.

To determine any additional value in the evaluation of safety levels by adding an appended oncology module to the Institute for Healthcare Improvement's Global Trigger Tool (GTT).Comparison of two independent retrospective chart reviews: one review team using the general GTT method and one using the general GTT method plus the appended oncology module on the same inpatient charts.The Department of Clinical Oncology at a Danish University Hospital (1000 beds).All inpatients admitted to the hospital in 2010, n = 3692, biweekly sample of 10 admission charts resulting in a double review of 240 charts.Total number of identified adverse events (AEs), distribution of identified AEs in the harm categories of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), AEs per 100 admissions and AEs per 1000 admission days.No significant (95% confidence interval) difference was found between review teams using the general GTT versus the general GTT plus the appended oncology module on the total number of identified AEs, AEs per 100 admissions, AEs per 1000 admission days or in the overall distribution of identified AEs in the five NCC MERP harm categories.The study showed that adding the appended oncology module to the GTT did not increase its value regarding the evaluation of safety levels. This finding could be due to the measurement error of the GTT. Further studies evaluating the measurement properties and the specific additional modules to the general GTT are needed.

Abstract Objective To evaluate the inter-rater reliability of results from Global Trigger Tool (GTT) reviews when one of the three reviewers remains consistent, while one or two reviewers rotate. Design Comparison of results from retrospective record review performed as a cross-sectional study with three review teams each consisting of two non-physicians and one physician; Team I (three consistent reviewers), Team II (one of the two non-physician reviewers or/and the physician from Team I are replaced for different review periods) and Team III (three consistent reviewers different from reviewers in Team I and Team II). Setting Medium-sized hospital trust in Northern Norway. Participants A total of 120 records were selected as biweekly samples of 10 from discharge lists between 1 July and 31 December 2010 for a 3-fold review. Intervention Replacement of review team members was tested to assess impact on inter-rater reliability and adverse events measurment. Main Outcome Measure(s) Inter-rater reliability assessed with the Cohen kappa coefficient between different teams regarding the presence and severity level of adverse events. Results Substantial inter-rater reliability regarding the presence and severity level of adverse events was obtained between Teams I and II, while moderate inter-rater reliability was obtained between Teams I and III. Conclusions Replacement of reviewers did not influence the results provided that one of the non-physician reviewers remains consistent. The experience of the consistent reviewer can result in continued consistency in interpretation with the new reviewer through discussion of events. These findings could encourage more hospital to rotate reviewers in order to optimize resources when using the GTT.

To determine the inter-rater reliability of the Institute for Healthcare Improvement's Global Trigger Tool (GTT) in a practice setting, and explore the value of individual triggers.Prospective assessment of application of the GTT to monthly random samples of hospitalized patients at four hospitals across three regions in the USA.Mayo Clinic campuses are in Minnesota, Arizona and Florida.A total of 1138 non-pediatric inpatients from all units across the hospital.GTT was applied to randomly selected medical records with independent assessments of two registered nurses with a physician review for confirmation.The Cohen Kappa coefficient was used as a measure of inter-rater agreement. The positive predictive value was assessed for individual triggers.Good levels of reliability were obtained between independent nurse reviewers at the case-level for both the occurrence of any trigger and the identification of an adverse event. Nurse reviewer agreement for individual triggers was much more varied. Higher agreement appears to occur among triggers that are objective and consistently recorded in selected portions of the medical record. Individual triggers also varied on their yield to detect adverse events. Cases with adverse events had significantly more triggers identified (mean 4.7) than cases with no adverse events (mean 1.8).The trigger methodology appears to be a promising approach to the measurement of patient safety. However, automated processes could make the process more efficient in identifying adverse events and has a greater potential of improving care delivery and patient 'outcomes'.

To investigate whether a priori selection of patient records using unexpectedly long length of stay (UL-LOS) leads to detection of more records with adverse events (AEs) compared to non-UL-LOS.To investigate the opportunities of the UL-LOS, we looked for AEs in all records of patients with colorectal cancer. Within this group, we compared the number of AEs found in records of patients with a UL-LOS with the number found in records of patients who did not have a UL-LOS.Our study was done at a general hospital in The Netherlands. The hospital is medium sized with approximately 30 000 admissions on an annual basis. The hospital has two major locations in different cities where both primary and secondary care is provided.The patient records of 191 patients with colorectal cancer were reviewed.Number of triggers and adverse events were the primary outcome measures.In the records of patients with colorectal cancer who had a UL-LOS, 51% of the records contained one or more AEs compared with 9% in the reference group of non-UL-LOS patients. By reviewing only the UL-LOS group with at least one trigger, we found in 84% (43 out of 51) of these records at least one adverse event.A priori selection of patient records using the UL-LOS indicator appears to be a powerful selection method which could be an effective way for healthcare professionals to identify opportunities to improve patient safety in their day-to-day work.

The implementing of the WHO Surgical Safety Checklist (SSC) has helped to improve patient safety. The aim of this study was to assess the level of compliance of the SSC, and incorporating the non-compliances as 芦triggers禄 in the Global Trigger Tool (GTT). Acute Geriatric Hospital (200 beds). Retrospective study, study period: 2011-2014. The SSC formulary and the methodology of the GTT were used for the analysis of electronic medical records and the compliance with the SSC. The NCCP MERP categories were used to assess the severity of the harm. Out of all the electronic medical records (EMR), a total of 227 (23.6%) discharged patients (1.7% of interventions in the four year study period) were analysed. All (100%) of the EMR included the SSC, with 94.4% of the items being completed, and 28.2% of SSC had all items completed in the 3 phases of the process. Surgical adverse events decreased from 16.3% in 2011 to 9.4% in 2014 (P=.2838, not significant), and compliance with all items of SSC was increased from 18.6% to 39.1% (P=.0246, significant). The GTT systematises and evaluates, at low cost, the triggers and incidents/ AEs found in the EMR in order to assess the compliance with the SSC and consider non-compliance of SSC as 芦triggers禄 for further analysis. This strategy has never been referred to in the GTT or in the SCC formulary.

目的：比较应用美国健康促进研究所推出的全面触发工具（GTT）主动监测药品不良事件（ADE）与采用自愿报告系统上报的ADE,为更好地应用两种监测方法预防和减少药品不良事件提供参考。方法：回顾性分析某院2014年应用GTT监测的成年住院患者的ADE与同期医院自愿报告的ADE的特点。结果：自愿上报ADE的可预防率为4.08%,GTT监测为18.75%。ADE相关患者中内科明显多于外科。自愿上报ADE中E级为主,且有F级、H级事件,GTT监测的ADE中E级与F级事件较多。ADE涉及的给药途径以静滴、口服和皮下给药为主,涉及的药品中频率最高的是中药、抗肿瘤药和胰岛素。结论：GTT监测与自愿上报两种方法监测到的ADE类型有一定互补性,建议医疗机构同时应用两种方法,以更好地预防和减少ADE的发生。

Background The Institute for Healthcare Improvement encourages use of the Global Trigger Tool to objectively determine and monitor adverse events (AEs). Setting Baylor Health Care System (BHCS) is an integrated healthcare delivery system in North Texas. The Global Trigger Tool was applied to BHCS's eight general acute care hospitals, two inpatient cardiovascular hospitals and two rehabilitation/long-term acute care hospitals. Strategy Data were collected from a monthly random sample of charts for each facility for patients discharged between 1 July 2006 and 30 June 2007 by external professional nurse auditors using an MS Access Tool developed for this initiative. In addition to the data elements recommended by Institute for Healthcare Improvement, BHCS developed fields to permit further characterisation of AEs to identify learning opportunities. A structured narrative description of each identified AE facilitated text mining to further characterise AEs. Initial findings Based on this sample, AE rates were found to be 68.1 per 1000 patient days, or 50.8 per 100 encounters, and 39.8% of admissions were found to have ≥1 AE. Of all AEs identified, 61.2% were hospital-acquired, 10.1% of which were associated with a National Coordinating Council – Medical Error Reporting and Prevention harm score of “H or I” (near death or death). Future Direction To enhance learning opportunities and guide quality improvement, BHCS collected data—such as preventability and AE source—to characterise the nature of AEs. Data are provided regularly to hospital teams to direct quality initiatives, moving from a general focus on reducing AEs to more specific programmes based on patterns of harm and preventability.

Record review is the most used method to quantify patient safety. We systematically reviewed the reliability and validity of adverse event detection with record review. A systematic review of the literature. We searched PubMed, EMBASE, CINAHL, PsycINFO and the Cochrane Library and from their inception through February 2015. We included all studies that aimed to describe the reliability and/or validity of record review. Two reviewers conducted data extraction. We pooled 魏 values (魏) and analysed the differences in subgroups according to number of reviewers, reviewer experience and training level, adjusted for the prevalence of adverse events. In 25 studies, the psychometric data of the Global Trigger Tool (GTT) and the Harvard Medical Practice Study (HMPS) were reported and 24 studies were included for statistical pooling. The inter-rater reliability of the GTT and HMPS showed a pooled 魏 of 0.65 and 0.55, respectively. The inter-rater agreement was statistically significantly higher when the group of reviewers within a study consisted of a maximum five reviewers. We found no studies reporting on the validity of the GTT and HMPS. The reliability of record review is moderate to substantial and improved when a small group of reviewers carried out record review. The validity of the record review method has never been evaluated, while clinical data registries, autopsy or direct observations of patient care are potential reference methods that can be used to test concurrent validity.

The implementing of the WHO Surgical Safety Checklist (SSC) has helped to improve patient safety. The aim of this study was to assess the level of compliance of the SSC, and incorporating the non-compliances as 芦triggers禄 in the Global Trigger Tool (GTT). Acute Geriatric Hospital (200 beds). Retrospective study, study period: 2011-2014. The SSC formulary and the methodology of the GTT were used for the analysis of electronic medical records and the compliance with the SSC. The NCCP MERP categories were used to assess the severity of the harm. Out of all the electronic medical records (EMR), a total of 227 (23.6%) discharged patients (1.7% of interventions in the four year study period) were analysed. All (100%) of the EMR included the SSC, with 94.4% of the items being completed, and 28.2% of SSC had all items completed in the 3 phases of the process. Surgical adverse events decreased from 16.3% in 2011 to 9.4% in 2014 (P=.2838, not significant), and compliance with all items of SSC was increased from 18.6% to 39.1% (P=.0246, significant). The GTT systematises and evaluates, at low cost, the triggers and incidents/ AEs found in the EMR in order to assess the compliance with the SSC and consider non-compliance of SSC as 芦triggers禄 for further analysis. This strategy has never been referred to in the GTT or in the SCC formulary.