Measuring adverse events and levels of harm in pediatric inpatients with the global trigger tool

Pediatrics

Volumn 130, Issue 5, 2012, Pages

  Kirkendall, Eric S ^a   Kloppenborg, Elizabeth ^a   Papp, James ^a   White, Denise ^a   Frese, Carol ^a   Hacker, Deborah ^a   Schoettker, Pamela J ^a   Muething, Stephen ^a   Kotagal, Uma ^a  

^a CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER   (United States)

Author keywords

Adverse events; Global trigger tool; Inpatient harm; Medical errors; Patient safety

Indexed keywords

ADULT; ADVERSE DRUG REACTION; ARTICLE; CHILD; CHILD HEALTH CARE; CLINICAL ASSESSMENT TOOL; DIAGNOSTIC VALUE; EARLY INTERVENTION; EMERGENCY WARD; FEMALE; FOLLOW UP; GLOBAL TRIGGER TOOL; HEALTH CARE DELIVERY; HEALTH HAZARD; HOSPITAL PATIENT; HOSPITAL READMISSION; HOSPITALIZATION; HUMAN; IATROGENIC DISEASE; INTENSIVE CARE; INTENSIVE CARE UNIT; LENGTH OF STAY; MAJOR CLINICAL STUDY; MALE; MEDICAL RECORD; PATIENT MONITORING; POSTOPERATIVE PERIOD; PRIORITY JOURNAL; QUALITY CONTROL; RETROSPECTIVE STUDY; RISK ASSESSMENT; RISK FACTOR; SCHOOL CHILD; TERTIARY HEALTH CARE; TREATMENT OUTCOME; TREATMENT WITHDRAWAL;

EID: 84868629658     PISSN: 00314005     EISSN: 10984275     Source Type: Journal    
DOI: 10.1542/peds.2012-0179     Document Type: Article

References (30)

1. Kohn LT, Corrigan J, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000
2. Bates DW, Evans RS, Murff H, Stetson PD, Pizziferri L, Hripcsak G. Detecting adverse events using information technology. J Am Med Inform Assoc. 2003;10(2):115-128 (Pubitemid 36397587)
3. de Wet C, Bowie P. The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records. Postgrad Med J. 2009;85(1002):176-180
4. Franklin BD, Birch S, Schachter M, Barber N. Testing a trigger tool as a method of detecting harm from medication errors in a UK hospital: a pilot study. Int J Pharm Pract. 2010;18(5):305-311
5. Levtzion-Korach O, Frankel A, Alcalai H, et al. Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant. Jt Comm J Qual Patient Saf. 2010;36(9):402-410
6. Matlow AG, Cronin CM, Flintoft V, et al. Description of the development and validation of the Canadian Paediatric Trigger Tool. BMJ Qual Saf. 2011;20(5):416-423
7. Muething SE, Conway PH, Kloppenborg E, et al. Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis. Qual Saf Health Care. 2010;19(5):435-439
8. Naessens JM, Campbell CR, Huddleston JM, et al. A comparison of hospital adverse events identified by three widely used detection methods. Int J Qual Health Care. 2009;21(4):301-307
9. Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? Ann Intern Med. 2008;149 (2):100-108 (Pubitemid 352008597)
10. 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 - 2134
11. Resar RK, Rozich JD, Classen D. Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care. 2003;12(suppl 2):ii39-ii45 (Pubitemid 37542038)
12. Resar RK, Rozich JD, 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 -590
13. 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 (Pubitemid 36723946)
14. Matlow A, Flintoft V, Orrbine E, et al. The development of the Canadian paediatric trigger tool for identifying potential adverse events. Healthc Q. 2005;8(spec no): 90-93
15. Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics . 2008;121 (4). Available at: www.pediatrics.org/cgi/ content/full/121/4/e927
16. Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events. 2nd ed. Cambridge, MA: Institute for Healthcare Improvement; 2009
17. Classen DC, Resar R, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581-589
18. Elixhauser A, Pancholi M, Clancy CM. Using the AHRQ quality indicators to improve health care quality. Jt Comm J Qual Patient Saf. 2005;31(9):533 -538
19. Good VS, Saldaña M, Gilder R, Nicewander D, Kennerly DA. Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterisation of adverse events to support patient safety learning opportunities. BMJ Qual Saf. 2011;20(1):25-30
20. Naessens JM, O 'Byrne TJ, Johnson MG, Vansuch MB, McGlone CM, Huddleston JM. Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger Tool. Int J Qual Health Care. 2010;22(4):266 -274
21. World Health Organization. Collaborating Centers for International Drug Monitoring. World Health Organization Publication DEM/ NC/84.153 (E). Geneva, Switzerland: WHO; 1984. Available at: http://apps.who.int/iris/ handle/10665/61950. Accessed August 27, 2012
22. National Coordinating Council for Medication Error Reporting and Prevention. Types of Medication Errors. Available at: www.nccmerp. org/medErrorCatIndex.html. Updated February 20, 2001. Accessed May 24, 2011
23. Amin SG. Control charts 101: a guide to health care applications. Qual Manag Health Care. 2001;9(3):1-27
24. Holdsworth MT, Fichtl RE, Raisch DW, et al. Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. Pediatrics. 2007;120(5):1058-1066 (Pubitemid 350085540)
25. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16): 2114-2120 (Pubitemid 32367829)
26. Kaushal R, Jaggi T, Walsh K, Fortescue EB, Bates DW. Pediatric medication errors: what do we know? What gaps remain? Ambul Pediatr. 2004;4(1):73-81 (Pubitemid 38180876)
27. Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc. 1998;5(3):305 -314
28. Landis JR, Koch GG. An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers. Biometrics. 1977;33(2): 363-374 (Pubitemid 8131514)
29. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174 (Pubitemid 8054849)
30. Thomas EJ, Lipsitz SR, Studdert DM, Brennan TA. The reliability of medical record review for estimating adverse event rates. Ann Intern Med. 2002;136(11):812- 816