Transcript STORMS ON THE SHORES OF THE SEA OF TRANQUILITY: MAN

The Role of Trigger Tools in Detecting
Adverse Events in Hospitalized
Children: Filling in the Blanks
Anne Matlow MD FRCPC
Medical Director, Patient Safety
Hospital for Sick Children, Toronto
Associate Director, Centre for Patient Safety
University of Toronto
NICHQ 2010
DISCLOSURE
I am Canadian
And I won’t rub it in!!!
The Role of Trigger Tools in Detecting
Adverse Events in Hospitalized
Children: Filling in the Blanks
Anne Matlow MD FRCPC
Medical Director, Patient Safety
Hospital for Sick Children, Toronto
Associate Director, Centre for Patient Safety
University of Toronto
NICHQ 2010
Trigger tool
9 year old girl. Fell out of bed. Presented to
ER with decreased level of consciousness and
hypertension. Admitted to PICU. Management
focused on determining cause of lethargy (CT,
MRI) and treating hypertension. Nephrology
consulted when BP still elevated. Elicited
history from Mom of periorbital edema.
Diagnosis post- infectious glomerulonephritis
with hypertension and encephalopathy. On
review, proteinuria and hematuria present on
admission. Improved on antihypertensives and
low sodium diet.
Country
Charts
Reviewed
Year
Incidence of AE
Preventable
Canada
3,745
2000
7.5%
37%
Denmark
1,097
1999
9.0%
40.4%
New Zealand
6,579
1998
12.9%
37%
England
1,014
1998
11.7%
50%
Australia
14,000
1992
16.6%
51%
USA (Utah &
Colorado)
15,000
1992
2.9%
-
USA (NY)
30,121
1984
3.7%
58%
SCREENING/EXPLICIT CRITERIA
1. Unplanned admission pre
2. Unplanned readmit within
12 months
3. Hospital incurred injury
4. Adverse drug event
5. Unplanned transfer to ICU
6. Unplanned transfer to
another acute care hosp
7. Unplanned return to OR
8. Unplanned removal, injury
or repair intra-operatively
9. Other patient complications
10. New neurological deficit
11. Unexpected death
12. Inappropriate discharge home
13. Cardiac/ resp arrest / low
APGAR score
14. Injury related to delivery or
abortion
15. Hospital acquired infection/
sepsis
16. Documented dissatisfaction
with care
17. Documentation or
correspondence re litigation
18. Any other undesirable
outcomes
Detecting Adverse Events
Method
AE/1000 admissions
Incident Reports (2-8%)
Retrospective Chart Review
Stimulated Voluntary Reports
Automated Flags
Daily chart review
Automated Flags and Daily review
5
30
30
55*
85
130*
*triggers
Jha J Am Med Inf Assoc 1998;5:305
O'Neil Ann Int Med 1993;119:370
Original slide courtesy of Dr Philip Hebert
• Manual
– Paper-based retrospective chart review
• Semi-automated
– Screening electronically + review manually
– Prospective, Concurrent, Retrospective
• Fully automated
– Screening + reviewing electronically
– Only some types of AEs
• e.g. INR>6 in pts on warfarin, ICD-9 codes
– Not if implicit judgement is required
Voluntary reporting and computerized
surveillance not as good as chart review
Manual Chart Review
Computerized
Surveillance
Voluntary
Reporting
67
331
3 20
205
Classen DC, Pestotnik S. Evans S et al. Computerized surveillance of adverse drug events in hospitalized patients. JAMA. 1991;226:2847
Sensitivity of routine system for reporting patient
safety incidents in an NHS hospital: retrospective
patient case note review Sari BMJ 2007;334:79
• 324 patient safety incidents were identified in
230/1006 admissions (22.9%; 95% CI 20.3% to 25.5%).
• 270 (83%) patient safety incidents were identified by
case note review (TT) only,
• 21 (7%) by the routine reporting system only, and 33
(10%) by both methods.
– TT 12x more sensitive than routine reporting
system
Trigger Tool 2 stage Review
TRIGGERS
ADVERSE EVENTS
Rate of Adverse Events without using
Trigger Tools
–All adverse events: ~1.0-3 / 100
patients
(Miller Pediatrics 2003 and 2004; Slonim Pediatrics 2003;
Woods Pediatrics 2005; )
–Adverse drug events:
• True: 2.1-11/ 100 admissions
• Potential: ADE 14.6/ 100
admissions
• 22-60% preventable (Kaushal JAMA 2001;
Holdsworth APAM 2003; Kunac Pediatric Drugs 2009)
Adverse Events in the NICU
Sharek et al. Pediatrics. 2006:118:1332-1340
n=554
74 per 100
admissions of
which 56%
preventable
Incidence of Adverse Events and
Negligence in Hospitalized Patients
Brennan NEJM 1991
Adverse events and preventable
adverse events in children
Woods Peds 2005:115:155
Adverse events and preventable adverse
events in children
Woods D. Pediatrics. 2005 Jan;115:155-60.
Quality in Australian Health Care Study
Wilson Med J Aust 1995
Diagnostic errors are common
cause of adverse events
NY 1984
Utah/Col 1992
Australia 1992
NZ 1998
UK 1999
Canada 2001
Sweden 2003
AE rate
Diagnostic
3.7%
2.9%
16.6%
13.1%
10.8%
7.5%
14.2%
7%
6.9%
13.3%
8%
4.2%
10.6%
11.3%
De Vries QSHC 2008; Soop IJQHC 2009
DIAGNOSTIC ERROR
Graber Arch Int Med 2005
Occurrences for which diagnosis was
1. Unintentionally delayed (sufficient info was
available earlier),
2. Wrong (another diagnosis was made before
the correct diagnosis), or
3. Missed (no diagnosis was ever made),
as judged from the eventual appreciation of
more definitive information
CAN TRIGGER TOOLS HELP
US IDENTIFY DIAGNOSTIC
ERROR?
Sensitivity and Specificity of the
Canadian Paediatric Trigger Tool
Adverse Event
Trigger
Yes
Yes
78
No
283
Total
361 (60%)
No
11
219
230
Total
89 (15%)
502
591
89 patients experienced at least 1 AE
Clinical Care Process vs #AE
Surgical
Medical Procedure
Diagnostic
Clinical management
50
16
14
10
Drug/Fluid
Fractures
System Issue
Other
Total number of AEs
10
1
1
21
123
Clinical Care Process vs #AE
Surgical
Medical Procedure
Diagnostic
Clinical management
50
16
14
10
Drug/Fluid
Fractures
System Issue
Other
Total number of AEs
10
1
1
21
123
11.4% of adverse
events were
diagnostic
Distribution of AEs by Age Category
Surg
D/ FL
Other
4
Clin
Man
9
2
12
0-28 d
18
Med
Proc
11
Diag
29- 365 d
11
2
4
0
1
9
366 d5 yr
14
0
3
0
6
1
>5 yr
7
3
3
1
1
1
Total #
AEs
50
16
14
10
10
23
DIAGNOSTIC ERROR
Delayed diagnosis of post streptococcal
glomerulonephritis in 9 year old. Presented with
hypertension and decreased level of consciousness.
Work up focused on neurological findings. Diagnosis
actually glomerulonephritis with hypertension
and encephalopathy. Delay in initiating appropriate
treatment. Improved on antihypertensives and
low sodium diet.
CAN TRIGGER TOOLS HELP
US IDENTIFY DIAGNOSTIC
ERROR?
METHODOLOGY DEPENDENT
CPTT
Two types of Second stage review
Focused Chart Review
- Facilitates standardized
second phase chart
review
- More efficient
- Better to show
improvement over time?
Complete Chart Review
- ? Finds more AEs?
- ? Can find different AEs eg
diagnostic error?
FOCUSING ON DIAGNOSTIC
ERROR WILL FILL IN A BLANK