Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger Tool

Naessens, James M.; O’Byrne, Thomas J.; Johnson, Matthew G.; VanSuch, Monica; McGlone, C.; Huddleston, Jeanne M.

doi:10.1093/intqhc/mzq026

Cited by 96 publications

(134 citation statements)

References 12 publications

(18 reference statements)

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“…The underlying rationale is that surveillance of events that have led to harm is a more focused and hence more effective approach to developing a strategy for injury reduction . The method is paper-based, in other words, it does not require or depend on the use of health information systems, although many have identified the benefits of integration with the electronic patient record (Classen et al 2011;Naessens et al 2010). Use of the GTT seems to be on the rise at least in the USA and in the Nordic countries, as part of large organizational, as well as national patient safety programmes.…”

Section: Introductionmentioning

confidence: 99%

Use of the Global Trigger Tool in patient safety improvement efforts: Nordic experiences

Doupi

Svaar²,

Bjørn³

et al. 2014

Cogn Tech Work

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The Global Trigger Tool (GTT) developed by the Institute for Healthcare Improvement is a method for retrospective patient record review based on the use of 'triggers'-signals of potential adverse events that have caused patient harm. The method has the purpose of patient safety measurement and monitoring among adult inpatient populations and has been increasingly popular among Nordic countries. Use of the GTT in the Nordic area has been part of broader legal and policy actions and initiatives supportive of patient safety promotion and is being used to establish also national level estimates of patient safety incidents. Limitations of the method are its dependency on quality of documentation and the varying inter-rater reliability observed in many studies. Strengths of the GTT are its ability to detect larger numbers, as well as different types of adverse events when compared to other incident detection methods, hence it is a good addition to the palette of means for organizational patient safety monitoring. Research on reliability, usefulness and implementation approaches of the GTT, including its automation, is ongoing in the Nordic countries and is expected to generate useful input for the international patient safety community.

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Section: Introductionmentioning

confidence: 99%

Use of the Global Trigger Tool in patient safety improvement efforts: Nordic experiences

Doupi

Svaar²,

Bjørn³

et al. 2014

Cogn Tech Work

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“…The harm rate of 9% in Wales using the GTT is considerably lower than any of the US-based studies examining harm in secondary care settings 4,21,41,75 and it is very unlikely that this reflects a true difference in AE rates between the US and UK health systems. Some GTT studies do not exclude AEs present on admission and it remains unclear what the GTT is actually measuring.…”

Section: The Comparison Of the Global Trigger Tool And Two-stage Retrmentioning

confidence: 86%

“…19 Even higher rates of detection of AEs using the GTT methodology have been confirmed in other studies, for which AE rates in hospitalised patients are consistently reported to be > 30% of all inpatient admissions. 4,21,[41][42][43] Naessens et al 41 assessed the ability of nurse reviewers, using GTT methodology, to detect AEs in four US hospitals and reported favourable levels of detection of both triggers (κ = 0.63, 95% CI 0.58 to 0.68) and AEs (κ = 0.51, 95% CI 0.45 to 0.57). In a study evaluating the reliability of the GTT in tracking local and national AE rates, agreement by nurse reviewers was reported to be within a range of κ = 0.40-0.60.…”

Section: The Measurement Of Harm In Inpatient Settings: An Overviewmentioning

confidence: 99%

“…In the absence of a structured phase 2 process in the GTT, harm determination is viewed to be more prone to systematic bias. 5,41,43 Further questions arise as to what the GTT methodology is actually measuring, as, even when events caused by omission are not quantified, rates of reported harm are threefold higher than when the Harvard method is used. It might well be that triggers are being misclassified as AEs and/or multiple triggers relating to one AE are being classified as multiple AEs.…”

Section: A Comparative Analysis Of the Global Trigger Tool And The Hamentioning

confidence: 99%

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Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study

Mayor

Baines

Vincent

et al. 2017

Health Serv Deliv Res

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Background, objectives and settingDespite global activity over the past 15 years to improve patient safety, the measurement of adverse events (AEs) remains challenging.ObjectivesWe aimed to obtain definitive longitudinal data on harm across NHS Wales and to compare the performance of the Global Trigger Tool (GTT) with the two-stage retrospective review process, using our findings to consolidate an approach to the ongoing surveillance of harm in Wales.Data sourcesEleven of the 13 major Welsh NHS hospitals.Review methodsThe two-stage retrospective review methodology was used to quantify harm across NHS Wales. In total, 4536 inpatient episodes were screened for AEs by research nurses. Records that were highly suggestive of AEs were further assessed by physicians. NHS-led teams undertook GTT reviews on the same case notes.ResultsAt least one AE was determined in 10.3% of episodes of care [95% confidence interval (CI) 9.4% to 11.2%] and 51.5% were preventable (95% CI 46.9% to 56.1%). The percentage of patients identified with AEs using the GTT methodology was lower, at 9.0% (95% CI 8.82% to 9.18%). Differences in AEs were evident across study sites. Methods were developed to profile the risk of AEs in individual organisations by producing signatures of harm for each NHS site. Analysis indicated that neither the GTT nor the two-stage process was a candidate tool for routine surveillance, and a hybrid one-stage tool (Harm2), based on phase 1 findings, was developed for ongoing AE monitoring. Using the Harm2 tool, AEs were identified in 371 out of 3352 randomly selected discharge reviews (11.3%, 95% CI 10.2% to 12.4%), and 59.6% (95% CI 55.3 to 63.9) of these were preventable. In a cohort of randomly selected deceased patient reviews, at least one AE was determined in 315 out of 1018 admissions (30.1%, 95% CI 28.1% to 33.8%), and 61.7% (95% CI 57.5% to 65.9%) of these were preventable. Factors associated with AEs in the randomly selected discharge reviews included having peripheral vascular disease [odds ratio (OR) 2.52], hemiplegia (OR 2.27) or dementia (OR 2.27). No association with chronic disease was identified in the deceased episodes of care.LimitationsThe dependence on our health service partners in identifying notes to be reviewed, along with the small sample examined each month, limits the generalisability of these findings and rates were not standardised for hospital and size and level of services provided. We cannot rule out the possibility that the rates we report may be underestimated.ConclusionThe extent of harm detected across NHS Wales using both the two-stage retrospective review process and the new Harm2 tool conforms to the findings in the literature, but this is the first longitudinal study using these methods. With training and using a structured review process, non-physician reviewers can undertake case note review efficiently and effectively, and the rates of AEs and of the preventability and the breakdown of problems in care conform to those reported in studies in which physicians undertake these classifications. Whether the patient died or was discharged alive significantly influences the rate and composition of AEs. The Harm2 tool performed with moderate reliability in the determination of AEs.Future workFuture large-scale studies should attempt to specify types of AEs, such as hospital-acquired infections and surgical complications, to enable the surveillance of the specific types of harm as well as the overall level of AEs. In the longer term, we need to automate harm surveillance and set measures of harm alongside measures of the beneficial effects of health care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…Among other identified trigger tools were 25% dextrose, sodium polystyrene, steroids, vitamin K. Naessens et al showed anti-emetic trigger tool has the maximum probability followed by diphenhydramine and vitamin K [12]. Ganachari et al reported abrupt medication stoppage as the maximum probability followed by hypotension [6].…”

Section: Discussionmentioning

confidence: 99%

A Pharmacovigilance Study Using Tracer Techniques

Yerramilli¹

2014

Adv Pharmacoepidemiol Drug Saf

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Objective: To identify adverse drug reactions by using a comprehensive trigger tool method. To categorize the identified adverse drug reactions based upon their Probability, Severity, Harm and Preventability by using different scales.Methods: A single-center, Cross-sectional, observational study based on medication and laboratory trigger tool methodology was conducted over a period of six months. The World Health Organization definition of adverse drug reactions was adopted. A list of 17 triggers were used to trace the adverse drug reactions which were then analyzed to assess the causality by using Naranjo's scale, severity by Hartwig and Siegel scale, and harm by the National Coordinating Council for Medication Error Reporting and Preventing Index and preventability by Modified Schumock and Thornton scale. Results:A total of 100 suspected ADRs were collected and analyzed. The drug classes most commonly implicated with ADRs were cephalosporins (25%) followed by anti-diabetic agents (19%). According to Naranjo's scale, the reactions were categorized as probable (80%), possible (10%) and definite (5%). According to the modified Schumock and Thornton preventability scale, 20 cases (20%) were possibly preventable while 80 cases (80%) were not preventable. In 85 cases (85%) the suspected drug was withdrawn while in 10 cases (10%) no change in dose was made and in 5 cases (5%) the dose was altered. Conclusion:Pharmacovigilance using tracer techniques significantly increases the identification and reporting of ADRs. The tracer technique is relatively simple, sensitive, less expensive and largely effective compared to traditional methods. The Trigger tool provides an additional instrument in improving patient safety. This technique leads to an increase in awareness and reporting of ADRs and provide opportunities for the health care system to review drug selection and prescribing practices affecting patient outcomes.

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Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger Tool

Abstract: 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'.

Cited by 96 publications

References 12 publications

Use of the Global Trigger Tool in patient safety improvement efforts: Nordic experiences

Use of the Global Trigger Tool in patient safety improvement efforts: Nordic experiences

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study

A Pharmacovigilance Study Using Tracer Techniques

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