Global Trigger Tools: how do we measure safety in hospitals?

It makes me happy to drill down into a NZ government healthcare-safety website to find a link to Atul Gawande’s TED Talk How do we heal medicine? That is just an indicator, but a positive indicator, that NZ is paying attention to developments in methods to radically improve medical safety. For those who are new to this topic, this earlier post links to important resources: How to Stop Hospitals From Killing Us.

If we can measure safety effectively we have a much better chance of improving outcomes.  Here’s how the NZ HQSC describes the Global Trigger Tools:

The Commission is developing a work programme to help implement the Global Trigger Tools programme in New Zealand.

The Global Trigger Tools* programme is an international initiative to reduce patient harm caused by errors in hospitals. Currently most health service providers rely on voluntary reporting of errors to identify problems in their systems, however overseas research found that only 10-20 percent of errors are ever reported. While in the vast majority of cases these errors did not result in patient harm, tracking these events would help identify where improvements should be made.

The Global Trigger Tools programme takes a different approach to error reporting, rather than relying on people reporting errors, it analyses random samples of patient records looking for ‘triggers’ which indicate an error has been made. The information gained can then be used to improve the quality and safety of the services provided.

Carol Haraden is the Vice President of the Institute of Healthcare Improvement (IHI). IHI developed the Global Trigger Tool which the Commission is encouraging all DHBs to implement. The Commission is working to publish helpful resources to assist with implementation. In the short AV below, Carol is interviewed at the Asia Pacific Forum (APAC) on patient safety and asks why clinicians aren’t using a standardised approach to patient safety issues. She also talks about the importance of team-work in achieving improved patient safety.

The Global Trigger Tool has a focus on team-work as the methodology requires medical record reviews to be carried out by a team of trained reviewers who have a clinical background (usually nursing or pharmacy). This is a simple, validated, and cost effective methodology and has been widely used to identify, quantify and track patient harm.

The NZ implementation guide is excellent: The Global Trigger Tool: A Practical Implementation Guide for New Zealand District Health Boards [PDF, 1MB]

“Ground Zero” for evaluation of the effectiveness of this methodology is back at IHI: IHI Global Trigger Tool for Measuring Adverse Events. Here you can find a large resource library, from Training Record Sets to translations in Danish, German, Swedish.

The use of “triggers,” or clues, to identify adverse events (AEs) is an effective method for measuring the overall level of harm in a health care organization. The IHI Global Trigger Tool for Measuring AEs provides instructions for training reviewers in this methodology and conducting a retrospective review of patient records using triggers to identify possible AEs. This tool includes a list of known AE triggers as well as instructions for selecting records, training information, and appendices with references and common questions. The tool provides instructions and forms for collecting the data you need to track three measures:

  • Adverse Events per 1,000 Patient Days
  • Adverse Events per 100 Admissions
  • Percent of Admissions with an Adverse Event
For more general information on Trigger Tools and how to select the appropriate one, see the Introduction to Trigger Tools page.

In Measuring Safety at the IHI Safety First Blog, Frank Frederico summarized the recent Health Affairs paper: ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. In brief an expert review of closed patient charts by, typically, nurses and pharmacists appears to be much more effective than automated review — ten times more effective.

Measuring safety is crucial to improving health care, yet we still struggle to do it well.

Much of the challenge lies in safetys very nature: it is, inherently, a non-event—the absence of harm. So by necessity we focus instead on measuring what might be called ‘non-safety,’ usually in the form of harmful events. Fewer of these harmful events, we assume, means a safer health care system.

But which events do we count? How do you tally non-safety?

Our answer to that simple question is hugely consequential. Some efforts focus on infections, for instance. These are crucial harm events, but they are not the whole picture. Their absence does not, in and of itself, tell us that care delivery is safe.

At IHI, we’ve developed a freely available method of determining harm events that we call The Global Trigger Tool. Its advantage is comprehensiveness. Its drawback is time-intensiveness. We believe it’s a trade-off worth making. Here’s how the method works, as described in a recent Health Affairs paper:

‘Closed patient charts are reviewed by two or three employees —usually nurses and pharmacists, who are trained to review the charts in a systematic manner by looking at discharge codes, discharge summaries, medications, lab results, operation records, nursing notes, physician progress notes, and other notes or comments to determine whether there is a ‘trigger’ in the chart. A trigger could be a notation indicating, for example, a burn, a fall, or a reaction to a medication. Any notation of a trigger leads to further investigation into whether an adverse event occurred and how severe the event was. A physician ultimately has to examine and sign off on this chart review.’

We tested this system against other widely used methods to detect adverse events, and the results were stunning. The trigger tool detected 354 adverse events, while tools based on automated chart review fared far worse.  The Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators detected only 35 adverse events. The hospitals’ voluntary reporting systems? Just four.

You’ve all heard the old iceberg trope – 10 percent above water, 90 percent below. Well here it is, in sobering statistics. And those errors that occur below the water line of measurement aren’t actually invisible – not to patients, not to their families, and not to providers or to the functioning of our health care system.

The trigger tool is less time intensive than some other chart review methods, but as I mentioned earlier, it is not as cheap as automated methods such as AHRQ’s Patient Safety Indicators. Manual review simply takes more time. There is no way around that.

But nor is there a way around the danger of missing so many adverse events. Think about what other audits you conducting at your hospital that may be just as time-intensive. Surely, safety should rate the same level of attention and commitment.

So we want to hear from you:

How do you measure harm in your organization? 

Do you believe that you are capturing the entire scope of harm?

The good news, from our perspective, is that hospitals and regulators are increasingly using the trigger tool to identify the broader universe of adverse events. We will keep working to continue this trend—because only by facing the reality of adverse events can we truly address them.

In the UK, The Acute Trigger Tool is the approved UK version of IHI Global Trigger Tool. Again, lots of resources from the UK NHS Institute for Innovation and Improvement.

If you have access to JAMA Journal of the American Medical Association you can read Deciphering Harm Measurement, May 2012:

Improvement in health care quality and safety can be notable when measurement criteria are clear, evidence is strong, and policy and interventions are focused. Despite this potential, progress in reducing patient harm in hospitals has been slow.1 In an effort to catalyze progress, the Department of Health and Human Services (HHS) is funding a national program, Partnership for Patients (P4P), with the ambitious goal of reducing “preventable hospital-acquired conditions” by 40% by 2013, focused initially on 9 complications.2 Although the program’s goal formally includes only preventable harm, the HHS notes “the Partnership will target all forms of harm” and provide guidance to hospitals for reducing “all-cause harm.” Simultaneously, the list of “serious reportable events” for which the Centers for Medicare & Medicaid Services will modify physician and health care institution payment is increasing. However, delay in defining a measurement strategy for harm has slowed progress and has created confusion. The need to reach consensus on robust, pragmatic measures for assessing and tracking harm rates has therefore become urgent.

Next we’ll look at what Australia is doing.

How to Stop Hospitals From Killing Us

Johns Hopkins surgeon Marty Makary is co-developer of the life-saving checklist outlined in Atul Gawande’s bestselling book The Checklist Manifesto.

Dr. Makary’s new book was released September 18th Unaccountable/ What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care.

You can get an quick overview of the concepts from his September 21 WSJ article How to Stop Hospitals From Killing Us

(…) As doctors, we swear to do no harm. But on the job we soon absorb another unspoken rule: to overlook the mistakes of our colleagues. The problem is vast. U.S. surgeons operate on the wrong body part as often as 40 times a week. Roughly a quarter of all hospitalized patients will be harmed by a medical error of some kind. If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer’s. The human toll aside, medical errors cost the U.S. health-care system tens of billions a year. Some 20% to 30% of all medications, tests and procedures are unnecessary, according to research done by medical specialists, surveying their own fields. What other industry misses the mark this often?

It does not have to be this way. A new generation of doctors and patients is trying to achieve greater transparency in the health-care system, and new technology makes it more achievable than ever before.

I encountered the disturbing closed-door culture of American medicine on my very first day as a student at one of Harvard Medical School’s prestigious affiliated teaching hospitals. Wearing a new white medical coat that was still creased from its packaging, I walked the halls marveling at the portraits of doctors past and present. On rounds that day, members of my resident team repeatedly referred to one well-known surgeon as “Dr. Hodad.” I hadn’t heard of a surgeon by that name. Finally, I inquired. “Hodad,” it turned out, was a nickname. A fellow student whispered: “It stands for Hands of Death and Destruction.”

Stunned, I soon saw just how scary the works of his hands were. His operating skills were hasty and slipshod, and his patients frequently suffered complications. This was a man who simply should not have been allowed to touch patients. But his bedside manner was impeccable (in fact, I try to emulate it to this day). He was charming. Celebrities requested him for operations. His patients worshiped him. When faced with excessive surgery time and extended hospitalizations, they just chalked up their misfortunes to fate.

 Continue reading…