Multicenter Test of an Emergency Department Trigger Tool for Detecting Adverse Events

Abstract

Objectives-Traditional approaches to safety and quality screening in the emergency department (ED) are porous and low yield for identifying adverse events (AEs). A better approach may be in the use of trigger tool methodology. We recently developed a novel ED Trigger Tool (EDTT) using a multidisciplinary, multicenter approach. We conducted a multicenter test of this tool and assess its performance. Methods-Design and Participants: We studied the EDTT over a 13-month period at four EDs. All patients 18 and older with Emergency Severity Index (ESI) acuity levels of 1-3 seen by a provider were eligible. Reviewers completed standardized training modules. Each site reviewed 50 randomly selected visits per month. A first-level reviewer screened for presence of pre-defined triggers (findings that increase the probability of an AE). If no trigger is present, the review is deemed complete. When present, a trigger prompts an in-depth review for an AE. Any event identified is assigned a level of harm using the Medication Event Reporting and Prevention (MERP) Index, ranging from a near miss (A) to patient death (I). Events are noted as present on arrival (POA) or in the ED, an act of commission or omission and are assigned one of 4 event categories. A second level physician performs a confirmatory review of all AEs, and independently reviews 10% of cases to estimate the false negative rate. All AEs or potential AEs were reviewed in monthly group calls for consensus on findings. The primary outcome is the proportion of visits in which an AE is identified, overall and by site. Secondary outcomes include categories of events, distribution of harm ratings, and association of AEs with sociodemographic

The Emergency Department Trigger Tool: Validation and Testing to Optimize Yield

“…It also improves on the performance of a prior expert consensus-derived version of the EDTT that used manual screening for triggers and random sampling of records (typical trigger tool approach), which demonstrated an improved but still low yield. 29 Several promising triggers did not replicate in the validation sample due to their rarity (having used most of these cases in the derivation phase). It is possible that the cumulative burden of rare triggers could be significant, but we had insufficient power to address this issue.…”

“…These are significant improvements over traditional approaches for detection of AEs (reviewing all cases meeting common criteria), which we previously found to have a yield of just under 2%. It also improves on the performance of a prior expert consensus‐derived version of the EDTT that used manual screening for triggers and random sampling of records (typical trigger tool approach), which demonstrated an improved but still low yield 29 …”

“…28 We conducted a 1-year multicenter pilot study of this tool at four sites (monthly random sampling of 50 records) with an AE yield of 6.7%. 29 To further improve the efficiency of the EDTT and establish a basis for identifying individual triggers that did not rely on expert consensus alone, we returned to the broad set of candidate triggers and performed large scale testing of the 92 triggers that were mappable to our electronic medical record (EMR). We created and validated computerized queries to screen the EMR for these triggers, eliminating the manual trigger review step and allowing us to quickly select records for review from an enriched pool.…”

“…In 2013, we led a multicenter, multidisciplinary team to develop the ED Trigger Tool (EDTT) using a robust modified Delphi process, beginning with 104 candidate triggers and ultimately retaining 46 consensus‐derived triggers 28 . We conducted a 1‐year multicenter pilot study of this tool at four sites (monthly random sampling of 50 records) with an AE yield of 6.7% 29 . To further improve the efficiency of the EDTT and establish a basis for identifying individual triggers that did not rely on expert consensus alone, we returned to the broad set of candidate triggers and performed large scale testing of the 92 triggers that were mappable to our electronic medical record (EMR).…”

Medication Related Adverse Events in the Emergency Medical Services: Analysis of a Patient Safety Register

“…The aim of the TT methodology is to evaluate a de ned sample of patients to determine whether or not an AE and patient harm are present, and to measure the rates over time as improvement work focuses on the reduction of such events 29 . Use of the TT methodology is reported to provide a more time-effective, cost-effective, and sensitive means of identifying AEs and harm when compared with traditional methods, such as conventional chart review or voluntary reporting [25][26][27][28][29][30][31][32] . The speci c trigger tool used by the registry is a modi ed version of the Pitt AE trigger tool, a previously validated prehospital speci c trigger tool with a focus on high-risk case types 22 .…”