'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured

Health Affairs

Volumn 30, Issue 4, 2011, Pages 581-589

  Classen, David C ^a   Resar, Roger ^b   Griffin, Frances ^b   Federico, Frank ^b   Frankel, Terri ^b   Kimmel, Nancy ^c   Whittington, John C ^b   Frankel, Allan ^d   Seger, Andrew ^d   James, Brent C ^e  

^a UNIVERSITY OF UTAH   (United States)

^b INSTITUTE FOR HEALTHCARE IMPROVEMENT   (United States)

^c MISSOURI BAPTIST MEDICAL CENTER   (United States)

^d BRIGHAM AND WOMEN S HOSPITAL   (United States)

^e INTERMOUNTAIN HEALTHCARE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; ADVERSE DRUG REACTION; ARTICLE; DECUBITUS; FALLING; FEMALE; GLOBAL TRIGGER TOOL; HEALTH CARE QUALITY; HOSPITAL ADMISSION; HOSPITAL INFECTION; HOSPITAL PATIENT; HUMAN; LENGTH OF STAY; MAJOR CLINICAL STUDY; MALE; MEDICAL RECORD; MORTALITY; MULTICENTER STUDY; NAMED INVENTORIES, QUESTIONNAIRES AND RATING SCALES; PATIENT SAFETY; POSTOPERATIVE COMPLICATION; UNITED STATES; VENOUS THROMBOEMBOLISM; VOLUNTARY REPORTING;

FEMALE; HOSPITAL MORTALITY; HOSPITALS; HUMANS; MALE; MEDICAL AUDIT; MEDICAL ERRORS; MIDDLE AGED; QUALITY INDICATORS, HEALTH CARE; RETROSPECTIVE STUDIES; UNITED STATES;

EID: 79955618085     PISSN: 02782715     EISSN: 15445208     Source Type: Journal    
DOI: 10.1377/hlthaff.2011.0190     Document Type: Article

References (45)

1. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington (DC): National Academies Press; 2000.
2. Altman DE, Clancy C, Blendon RJ. Improving patient safety-five years after the IOM report. N Engl J Med. 2004; 351:2041-3.
3. Barach P, Berwick DM. Patient safety and the reliability of health care systems. Ann Intern Med. 2003; 138(12):997-8.
4. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002; 288(4):501-7.
5. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, Kerr EA, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-45.
6. Leape LL, Berwick DM. Five years after to err is human: what have we learned? JAMA. 2005;293(19): 2384-90.
7. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010; 363(22):2124-34.
8. Brennan TA, Gawande A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005;353(13):1405-9.
9. Milgate K, Hackbarth G. Quality in Medicare: from measurement to payment and provider to patient. Health Care Financ Rev. 2005/06; 27(2):91-101.
10. Miller RG, Druckman JL. The Patient Safety and Quality Improvement Act of 2005-the federal law and its implications for Missouri. Mo Med. 2007;104(1):17-20.
11. Aspden P, Corrigan JM, Wolcott J, Erickson SM. Patient safety: achieving a new standard for care. Washington (DC): National Academies Press; 2004.
12. McCannon CJ, Schall MW, Calkins DR, Nazem AG. Saving 100,000 lives in US hospitals. BMJ. 2006; 332(7553):1328-30.
13. Zhan C, Miller MR. Administrative data based patient safety research: a critical review. Qual Saf Health Care. 2003;12(Suppl 2):ii58-63.
14. Hougland P, Xu W, Pickard S, Masheter C, Williams SD. Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system. Med Care. 2006;44(7):629-36.
15. Masheter CJ, Hougland P, Xu W. Detection of inpatient health care associated injuries: comparing two ICD-9-CM code classifications. In: Hendriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in patient safety: from research to implementation: Volume 1. Rockville (MD): Agency for Healthcare Research and Quality; 2005.
16. West AN, Weeks WB, Bagian JP. Rare adverse medical events in VA inpatient care: reliability limits to using patient safety indicators as performance measures. Health Serv Res. 2008;43(1 Pt 1):249-66.
17. Brennan TA, Leape LL, Laird N, Herbert L, Localio AR, Lawther AG, et al. Incidence of adverse events and negligence in hospitalized patients-results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-6.
18. Institute for Healthcare Improvement. Introduction to trigger tools for identifying adverse events [Internet]. Cambridge (MA): IHI; [cited 2009 Oct 2]. Available from: http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/IntrotoTriggerToolsforIdentifyingAEs.html.
19. Haraden C, Leitch J. A national approach to improving patient safety: the Scottish Patient Safety Program. Health Aff (Millwood). 2011;30 (4):755-63.
20. Department of Health and Human Services, Office of Inspector General. Adverse events in hospitals: national incidence among Medicare beneficiaries [Internet]. Washington (DC): HHS; 2010 Nov [cited 2011 Jan 15]. Available from: http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
21. Institute for Healthcare Improvement. IHI Global Trigger Tool guide, version 7 [Internet]. Cambridge (MA): IHI; 2006 Dec [cited 2011 Mar 4]. Available from: http://www.unmc.edu/rural/patient-safety/tool-time/TT13-040207-5MillionLives/IHIGlobalTriggerToolGuideDec06.pdf.
22. To access the Appendix, click on the Appendix link in the box to the right of the article online.
23. Classen DC, Pestotnik SL, Evans RS, Burke JP. Description of a computerized adverse drug event monitor using a hospital information system. Hosp Pharm. 1992;27(9):774, 776-9, 783.
24. Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266(20): 2847-51.
25. Evans RS, Classen DC, Stevens LE, Pestotnik SL, Gardner RM, Lloyd JF, et al. Using a hospital information system to assess the effects of adverse drug events. Proc Annu Symp Comput Appl Med Care. 1993;161-5.
26. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997; 277(4):301-6.
27. Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care. 2003;12(3): 194-200.
28. Griffin FA, Classen DC. Detection of adverse events in surgical patients using the Trigger Tool approach. Qual Saf Health Care. 2008;17(4): 253-8.
29. Resar RK, Simmonds T, Haraden CR. A trigger tool to identify adverse events in the intensive care unit. Jt Comm J Qual Patient Saf. 2006; 32(10):585-90.
30. Sharek PJ, Horbar JD, Mason W, Bisarya H, Thurm CW, Suresh G, et al. Adverse events in the neonatal intensive care unit: development, testing, and findings of a NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics. 2006;118(4):1332-40.
31. Classen DC, Lloyd RC, Provost L, Griffin FA, Resar R. Development and evaluation of the Institute for Healthcare Improvement global trigger tool. J Patient Saf. 2008; 4(3):169-77.
32. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients-results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-84.
33. Griffin FA, Resar RK. IHI Global Trigger Tool for measuring adverse events. IHI Innovation Series White Papers. 2nd ed. Cambridge (MA): Institute for Healthcare Improvement; 2009.
34. National Coordinating Council for Medication Error Reporting and Prevention. About medication errors [Internet]. Rockville (MD): NCC MERP; c2011 [cited 2009 Oct 2]. Available from: http://www.nccmerp.org/medErrorCatIndex.html.
35. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000; 38(3):261-71.
36. O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993;119(5):370-6.
37. Giles S, Fletcher M, Baker M, Thomson R. Incident reporting and analysis: current status and future challenges. In: Walshe K, Boaden R, editors. Patient safety: research into practice. Maidenhead (UK): Open University Press; 2006.
38. Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10): 541-8.
39. Layde PM, Maas LA, Teret SP, Brasel KJ, Kuhn EM, Mercy JA, et al. Patient safety efforts should focus on medical injuries. JAMA. 2002; 287(15):1993-7.
40. Snow D, Classen DC. Kaiser Permanente experience with automating the IHI global trigger tool [Internet]. Paper presented at: AHRQ Annual Patient Safety Conference. Rockville, MD; 2010 Sep 29 [cited 2011 Mar 23]. Available from: http://www.ahrq.gov/about/annualconf10/nebeker_rosen_snow/snow.HTM.
41. Classen DC, Jaser L, Budnitz DS. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Jt Comm J Qual Patient Saf. 2010; 36(1):12-21.
42. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322(7285): 517-9.
43. Wilson R, Runciman W, Gibberd R, Harrison B, Newby L, Hamilton J. The quality in Australian health care study. Med J Aust. 1995;163(9): 458-71.
44. Baker G, Norton P, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678-86.
45. Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med. 2006;34(2):415-25.