Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval

Health Services Research

Volumn 49, Issue 5, 2014, Pages 1407-1425

  Kennerly, Donald A ^a   Kudyakov, Rustam ^b   Da Graca, Briget ^b   Saldaña, Margaret ^a   Compton, Jan ^a   Nicewander, David ^a   Gilder, Richard ^a  

^a BAYLOR HEALTH CARE SYSTEM   (United States)

^b SCOTT AND WHITE MEMORIAL HOSPITAL   (United States)

Author keywords

Adverse events; Global Trigger Tool

Indexed keywords

ADULT; ADVERSE OUTCOME; ARTICLE; COMMUNITY HOSPITAL; EMERGENCY CARE; GLOBAL TRIGGER TOOL; HEALTH CARE DELIVERY; HEALTH CARE SYSTEM; HOSPITAL ADMISSION; HUMAN; LENGTH OF STAY; MAJOR CLINICAL STUDY; MEDICAL RECORD; PATIENT SAFETY; TERTIARY CARE CENTER; TOTAL QUALITY MANAGEMENT; UNITED STATES; VOLUNTARY REPORTING; DRUG-RELATED SIDE EFFECTS AND ADVERSE REACTIONS; EPIDEMIOLOGY; HEALTH CARE QUALITY; INCIDENCE; INTEGRATED HEALTH CARE SYSTEM; MEDICAL ERROR; RETROSPECTIVE STUDY; STATISTICAL MODEL; STATISTICS AND NUMERICAL DATA;

ADULT; DELIVERY OF HEALTH CARE, INTEGRATED; DRUG-RELATED SIDE EFFECTS AND ADVERSE REACTIONS; HUMANS; INCIDENCE; LENGTH OF STAY; MEDICAL ERRORS; MEDICAL RECORDS; MODELS, STATISTICAL; PATIENT SAFETY; QUALITY INDICATORS, HEALTH CARE; RETROSPECTIVE STUDIES; TEXAS;

EID: 84908253558     PISSN: 00179124     EISSN: 14756773     Source Type: Journal    
DOI: 10.1111/1475-6773.12163     Document Type: Article

References (27)

1. Agency for Healthcare Research and Quality. 2010. " AHRQ's Efforts to Prevent and Reduce Health Care-Associated Infections " [accessed on December 5, 2013]. Available at http://www.ahrq.gov/research/findings/factsheets/errors-safety/haiflyer/index.html
2. Agency for Healthcare Research and Quality. 2012. " AHRQ Quality Indicators Software " [accessed on February 22, 2013]. Available at http://www.qualityindicators.ahrq.gov/software/default.aspx
3. Baker, G. R., P. G. Norton, V. Flintoft, R. Blais, A. Brown, J. Cox, E. Etchells, W. A. Ghali, P. Hebert, S. R. Majumdar, M. O'Beirne, L. Palacios-Derflingher, R. J. Reid, S. Sheps, and, R. Tamblyn,. 2004. " The Canadian Adverse Events Study: The Incidence of Adverse Events among Hospital Patients in Canada." Canadian Medical Association Journal 170 (11): 1678-86.
4. Classen, D., R. C. Lloyd, L. Provost, F. A. Griffin, and, R. Resar,. 2008. " Development and Evaluation of the Institute for Healthcare Improvement Global Trigger Tool." Journal of Patient Safety 4: 169-77.
5. Classen, D. C., R. K. Resar, F. A. Griffin, F. Federico, T. Frankel, N. L. Kimmel, J. D. Whittington, A. Frankel, A. C. Seger, and, B. C. James,. 2011. "Global Trigger Tool" Shows That Adverse Events in Hospitals May Be Ten Times Greater Than Previously Measured." Health Affairs 30 (4): 581-9.
6. The Commonwealth Fund. 2005. " Case Study: Promoting High Reliability Surgery at Kaiser Permanente " [accessed on December 4, 2005]. Available at http://www.commonwealthfund.org/Innovations/Case-Studies/2005/Jan/Case-Study&Promoting-High-Reliability-Surgery-at-Kaiser-Permanente.aspx
7. Dolores Menendez, M., I. Rancano, V. Garcia, C. Vallina, V. Herranz, and, F. Vazquez,. 2010. " Use of Different Patient Safety Reporting Systems: Much Ado about Nothing? " Revista de Calidad Asistencial 25 (4): 232-6.
8. Franklin IV, E. W., 2013. " Surgical Services." In Achieving STEEEP Health Care, edited by, D. J. Ballard, N. S. Fleming, J. T. Allison, P. B. Convery, and, R. Luquire, pp. 191-8. Boca Raton, FL: CRC Press.
9. Garrett, P. R., Jr., C. Sammer, A. Nelson, K. A. Paisley, C. Jones, E. Shapiro, J. Tonkel, and, M. Housman,. 2013. " Developing and Implementing a Standardized Process for Global Trigger Tool Application across a Large Health System." Joint Commission Journal on Quality and Patient Safety 39 (7): 292-7.
10. Good, V. S., M. Saldana, R. Gilder, D. Nicewander, and, D. A. Kennerly,. 2010. " 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." Quality and Safety in Health Care 20 (1): 25-30.
11. Griffin, F. A., and, R. K. Resar,. 2007. IHI Global Trigger Tool for Measuring Adverse Events. IHI Innovation Series. Cambridge, MA: Institute for Healthcare Improvement.
12. Haraden, C., and, J. Leitch,. 2011. " Scotland's Successful National Approach to Improving Patient Safety in Acute Care." Health Affairs 30 (4): 755-63.
13. Institute for Healthcare Improvement. 2013. " IHI Global Trigger Tool for Measuring Adverse Events " [accessed on October 15, 2013]. Available at http://www.ihi.org/knowledge/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx
14. Jha, A. K., and, D. C. Classen,. 2011. " Getting Moving on Patient Safety-Harnessing Electronic Data for Safer Care." New England Journal of Medicine 365 (19): 1756-8.
15. Kennerly, D., K. M. Richter, V. Good, J. Compton, and, D. J. Ballard,. 2011. " Journey to No Preventable Risk: The Baylor Health Care System Patient Safety Experience." American Journal of Medical Quality 26 (1): 43-52.
16. Kennerly, D. A., M. Saldaña, R. Kudyakov, B. da Graca, D. Nicewander, and, J. Compton,. 2013. " Description and Evaluation of Adaptations to the Global Trigger Tool to Enhance Value to Adverse Event Reduction Efforts." Journal of Patient Safety 9 (2): 87-95.
17. Landrigan, C. P., G. J. Parry, C. B. Bones, A. D. Hackbarth, D. A. Goldmann, and, P. J. Sharek,. 2010. " Temporal Trends in Rates of Patient Harm Resulting from Medical Care." New England Journal of Medicine 363 (22): 2124-34.
18. Levinson, D. R., 2010a. Adverse Events in Hospitals: Methods for Identifying Events. Washington, DC: Department of Health and Human Services, Officer of Inspector General.
19. Levinson, D. R., 2010b. Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries. Washington, DC: Department of Health and Human Services, Office of the Inspector General.
20. Mattsson, T. O., J. L. Knudsen, J. Lauritsen, K. Brixen, and, J. Herrstedt,. 2013. " Assessment of the Global Trigger Tool to Measure, Monitor and Evaluate Patient Safety in Cancer Patients: Reliability Concerns Are Raised." British Medical Journal Quality and Safety 22 (7): 571-9.
21. Naessens, J. M., C. R. Campbell, J. M. Huddleston, B. P. Berg, J. J. Lefante, A. R. Williams, and, R. A. Culbertson,. 2009. " A Comparison of Hospital Adverse Events Identified by Three Widely Used Detection Methods." International Journal for Quality in Health Care 21 (4): 301-7.
22. Naessens, J. M., T. J. O'Byrne, M. G. Johnson, M. B. Vansuch, C. M. McGlone, and, J. M. Huddleston,. 2010. " Measuring Hospital Adverse Events: Assessing Inter-Rater Reliability and Trigger Performance of the Global Trigger Tool." International Journal for Quality in Health Care 22 (4): 266-74.
23. Nuss, T. D., 2013. " Patient-Centered Care." In Achieving STEEEP Health Care, edited by, D. J. Ballard, N. S. Fleming, J. T. Allison, P. B. Convery, and, R. Luquire, pp. 139-50. Boca Raton, FL: CRC Press.
24. Rosen, A. K., P. Rivard, S. Zhao, S. Loveland, D. Tsilimingras, C. L. Christiansen, A. Elixhauser, and, P. S. Romano,. 2005. " Evaluating the Patient Safety Indicators: How Well Do They Perform on Veterans Health Administration Data? " Medical Care 43 (9): 873-84.
25. Rosenthal, M. B., 2007. " Nonpayment for Performance? Medicare's New Reimbursement Rule." New England Journal of Medicine 357 (16): 1573-5.
26. U.S. Department of Health and Human Services, n.d. " National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination " [accessed on 5 December, 2013]. Available at http://www.hhs.gov/ash/initiatives/hai/exec-summary.html
27. de Vries, E. N., M. A. Ramrattan, S. M. Smorenburg, D. J. Gouma, and, M. A. Boermeester,. 2008. " The Incidence and Nature of In-Hospital Adverse Events: A Systematic Review." Quality and Safety in Health Care 17 (3): 216-23.