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JULY 2005, VOL 82, NO 1 Patient Safety First PATIENT SAFETY FIRST Using trigger tools to enhance patient safety rigger tools offer an approach to standardizing error identifi- cation that may provide more consistent and accurate infor- T mation than traditional error reporting systems, such as incident reports, traditional chart audits, or vol- untary reporting.’ A trigger is a clue that helps a health care organization identify adverse events and assess the overaIl harm that occurs from medical care within that organization? Trigger tool methodology is based on identifymg and addressing errors that are highly associated with negative outcomes. TRIGGER TOOL K I T The Institute for Healthcare Improvement (IHI) has developed a Global Trigger Tool Kit2 that provides guidelines to help organizations meas- ure and evaluate harm that results from medical care. Harm to a patient may include “temporary or permanent impairment of physical or psychologi- cal body function or str~cture.”~(p~) The trigger tools provided by IHI address the following categories of harm: 0 temporary harm to the patient and required intervention, 0 temporary harm to the patient and required initial or prolonged hospi- talization, 0 permanent patient harm, 0 intervention required to sustain life, and 0 patient Triggers, as identified by IHI, relate to care processes, surgical procedures, medication administration, and care in an intensive care unit (ICU), perinatal department, or emergency department. Triggers related to care processes in- clude items such as transfusions, use of blood products, arrests, positive blood cultures, or infections. Surgical proce- dure triggers address items such as returns to surgery, intraoperative or postoperative death, surgical time, and surgical time greater than six hours. Medication triggers include items such as a prolonged international nor- malized ratio (ie, > 6) or partial throm- boplastin time (ie, > 100 seconds), diphenhydramine use, and naloxone use. Intensive care unit triggers are represented by the development of pneumonia, readmission to the ICU, in-unit proce- dures, and intubation or reintubation. The perinatal triggers include items such as Apgar scores lower than seven at five minutes and infant serum glucose less than 50 mg/dL. The two emergency department triggers are readmission to the emergency depart- ment within 48 hours and time in the emer- gency department longer than six hours. The IHI tool lut includes definitions for each of the triggers, as well as a data collection sheet and a summary sheet. The tool kit‘s guidelines teach clinical teams how to detect, rate, and record errors. The IHI suggests that health care organizationsreview T~gger i Suzanne C. Eeyea, RN ools can help health care organizations identify adverse events and may provide more consistent and accurate information than traditional error reporting systems. 20 randvomly selected charts per month, including the discharge summary and all coding, spending no more than 20 minutes on each chart. The chart reviewer records any triggers found in the files on a global trigger tool work- sheet, and data are normalized to report a summary of adverse events per 1,000 patient days. Data derived AORN JOURNAL 11 5

Using trigger tools to enhance patient safety

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Page 1: Using trigger tools to enhance patient safety

JULY 2005, VOL 82, NO 1 Patient Safety First

P A T I E N T S A F E T Y F I R S T

Using trigger tools to enhance patient safety

rigger tools offer an approach to standardizing error identifi- cation that may provide more consistent and accurate infor- T mation than traditional error

reporting systems, such as incident reports, traditional chart audits, or vol- untary reporting.’ A trigger is a clue that helps a health care organization identify adverse events and assess the overaIl harm that occurs from medical care within that organization? Trigger tool methodology is based on identifymg and addressing errors that are highly associated with negative outcomes.

TRIGGER TOOL KIT The Institute for Healthcare

Improvement (IHI) has developed a Global Trigger Tool Kit2 that provides guidelines to help organizations meas- ure and evaluate harm that results from medical care. Harm to a patient may include “temporary or permanent impairment of physical or psychologi- cal body function or str~cture.”~(p~) The trigger tools provided by IHI address the following categories of harm: 0 temporary harm to the patient and

required intervention, 0 temporary harm to the patient and

required initial or prolonged hospi- talization,

0 permanent patient harm, 0 intervention required to sustain life,

and 0 patient

Triggers, as identified by IHI, relate to care processes, surgical procedures, medication administration, and care in an intensive care unit (ICU), perinatal department, or emergency department. Triggers related to care processes in- clude items such as transfusions, use of blood products, arrests, positive blood cultures, or infections. Surgical proce- dure triggers address items such as

returns to surgery, intraoperative or postoperative death, surgical time, and surgical time greater than six hours.

Medication triggers include items such as a prolonged international nor- malized ratio (ie, > 6) or partial throm- boplastin time (ie, > 100 seconds), diphenhydramine use, and naloxone use. Intensive care unit triggers are represented by the development of pneumonia, readmission to the ICU, in-unit proce- dures, and intubation or reintubation.

The perinatal triggers include items such as Apgar scores lower than seven at five minutes and infant serum glucose less than 50 mg/dL. The two emergency department triggers are readmission to the emergency depart- ment within 48 hours and time in the emer- gency department longer than six hours.

The IHI tool lut includes definitions for each of the triggers, as well as a data collection sheet and a summary sheet. The tool kit‘s guidelines teach clinical teams how to detect, rate, and record errors. The IHI suggests that health care organizations review

T~gger i

Suzanne C. Eeyea, RN

ools can help health care

organizations identify adverse

events and may provide

more consistent and accurate information

than traditional error reporting

systems.

20 randvomly selected charts per month, including the discharge summary and all coding, spending no more than 20 minutes on each chart. The chart reviewer records any triggers found in the files on a global trigger tool work- sheet, and data are normalized to report a summary of adverse events per 1,000 patient days. Data derived

AORN JOURNAL 11 5

Page 2: Using trigger tools to enhance patient safety

JULY 2005, VOL 82, NO 1 Patient Safety First

from the review can be used in subsequent efforts to im- prove care and safety.

ADVERSE DRUG EVENTS TOOL In collaboration with ex-

perts, the IHI also has devel- oped the Trigger Toolfor Measuring Adverse Drug Euents,< a list of triggers that health care organizations can use in their efforts to exam- ine medication errors.’ The IHI list of medications is pro- vided as a beginning frame- work, and health care organi- zations can add or delete medications from the list. The IHI also provides a list of triggers for children younger than 18 years of age.

As with the Global Trigger Tool, the IHI suggests using a sampling plan and a monthly summary sheet. The MI pro- vides a standardized defini- tion for each trigger and guidelines about how to iden- fsfy and measure adverse medication events.

In addition, there is an interactive trigger tool for measuring adverse drug events on the IHI’s web site.” Data can be entered, and the tool will automatically calcu- late and graph adverse drug events per 1,000 doses and the percentage of admissions with an adverse drug event.

Focus ON IMPROVEMENT Using trigger tools, health

care organizations have a structured approach to meas- uring the overall rate of

Trigger tools provide health care

organizations with a structured

approach to measuting the overall rate of adverse events

that result in harm and developing

and implementing strategies to prevent future occurrences.

adverse events that result in harm and for developing and implementing stra teges to prevent future occurrences. Each of the surgical triggers helps perioperative chcians be more aware of high-risk situations in the OR. For example, if a surgical depart- ment’s patients are experienc- ing surgxal mfections, identi- fymg those infections through the use of a trigger tool can provide members of the team with more knowledge about the rate of and factors con- tributing to mfections. With this type of information, the team can work toward pre- venting subsequent infections.

Materials related to these trigger tool initiatives and additional materials about patient safety and health care improvement are pro- vided on the IHI web site at

http://www. ihi.org. Every clini- cian interested in improving the quality of care and en- hancing patient safety should investigate these resources. 03

SUZANNE C. BEYEA RN, PHD, FAAN

DARTMOUTH-HITCHCOCK MEDICAL CENTER LEBANON, NH

DIRECTOR OF NURSING RESEARCH

NOTES 1. R K Resar, J D Rozich, D Classen, ”Methodology and rationale for the measurement of harm with trig er tools,” Quality 6 Safety in Heath Care 24 Suppl2 (December 2003) ii39-ii45. 2. “Global Trigger Tool Kit- Version 6,” (January 2005) Insti- tute for Healthcare Improvement, http://zoww.ihi.org/NR/rdonlyres/E4

AAUE/2438/GlobalTriggerToolKit6 .pdf (accessed 13 May 2005). 3. ”NCC MEW index for cate- gorizing medication errors,” National Coordinating Council for Medication Error Reporting and Prevention, http://www.ncc merp.org/pdf/indexB W2001-06- 12.pdf(accessed 13 May 2005). 4. ”Trigger tool for measuring adverse drug events,” Institute for Healthcare Improvement, http://www. ihi.org/lHl/Kopics/Patien t Safetybdedicat ions ystems/rools/rrig ger%20Too1%2Ufor%2UMeasuring %20Adverse%20Dvug%20Even ts %2U(IHI%2UTooI) (accessed 13

4 B492O-3 ESB-4739-9761-8E3A7168

May 2005). 5. J D Rozich, C R Haraden, R K Resar, “Adverse drug event trig- er tool: A practical methodology

for measuring medication related harm,” Quality G. Safety in Health Care 12 (June 2003) 194-200. 6. “Trigger tool for measuring ADEs,” Institute for Healthcare Improvement, http://www.ihi.org /ihi/workspace/tools/trigger/ (access- ed 13 May 2005).

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