Transcript Global trigger tool

4th February 2009
Trigger Tools
Presenter:
Trigger ToolsLiz Baines
Patient Safety –
The Facts
Main Causes of Death:
1.
2.
3.
4.
Cardiovascular Disease
Cancer
Respiratory Disease
Adverse Events
Trigger Tools
What is an Adverse
Event?
“An unintended injury or complication
caused by medical management rather
than the disease process. The injury is
sufficiently serious to lead to prolongation
of hospitalisation or temporary of
permanent impairment or disability in the
patient”
Harvard Medical Practice Study 1990
Trigger Tools
A Safety Culture in
Healthcare
• People do not intend to cause harm
• Incidents are rarely due to single errors and
are often the end product of multiple factors
• Analyses of incidents : less focus on the
individual and more on the organisation
• What does this tell us about ‘our’ system
• Safety is everyone’s responsibility
Trigger Tools
Errors and Harm
• Not all errors result in harm
• Not all harm is as the result of errors
Trigger Tools
Rates of Error/Adverse Events in 7 international studies
50.00%
45.00%
Prospective
Observational
Study
40.00%
35.00%
30.00%
Retrospective
Notes Review
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Harvard (NY)
Trigger Tools
Utah
Australia
New Zealand
UK
Canada
Ethographic
study
Impact of adverse events
Direct costs
• Estimated cost of preventable adverse events in
the USA $10.1 billion dollars (Leape et al 1993)
• Study in Utah and Colorado estimated the cost of
adverse events to be $159,245,000.
• On average preventable drug events resulted in an
additional 4.6 days in length of stay
• In England healthcare associated infections are
estimated to cost over £1 billion pounds a year
Trigger Tools
Indirect costs
•
•
•
•
•
•
•
•
Increased pain and discomfort
Lost earnings
Impact on work & social lives
Psychological trauma
Disability
Death
Impact on carers and families
At any one time 1.4 million people worldwide are
suffering from infections acquired in hospital
Trigger Tools
Impact on Healthcare
workers
•
•
•
•
•
•
•
Profound consequences
Shame
Guilt
Litigation & complaints
Anxiety
Loss of confidence
Impact on families & co-workers
Trigger Tools
Why Trigger Tools?
• Conventional approaches to quantifying
adverse events:
– Voluntary Incident Reporting
– Record Reviews
– Observational databases
• 2000 The IHI Trigger Tool for Measuring
Adverse Drug Events (ADE)
• This was based on the principle of Triggers
Trigger Tools
Background
• Trigger Tools focus on identifying
harm as opposed to errors
• By focusing on events experienced
by patients it can help shift the
culture from individual blame for
errors.
• This can facilitate system redesign
Trigger Tools
Global Trigger Tool
• IHI Global Trigger Tool (GTT) goes beyond
medications
• Focus is on adverse events related to delivery
of care (acts of commission)
• Rather than issues related to substandard care
(omissions)
• Omissions often leads to judgment and
individual blame rather than focus on system
solutions.
Trigger Tools
Trigger Tools
What does the tool tell
you?
• Adverse Event Rate per 1000 patient days
40 per 1000 pt days = 4 per 100 pt days
1 per 25 days
In a 25 bed ward =
That is 1 patients harmed every day
• 25 per 1000 bed days = 2.5 per 100 pt days
In a 25 bed ward = 2.5 incidents in 4 days
That is a patient is harmed every other day
Trigger Tools
What else can it tell us?
• 1000 Lives Campaign Reporting Summary
Spreadsheet for the Trigger Tool
Trigger Tools
Frequency of Triggers 2005 -2007
140
120
100
80
Series1
60
40
20
Most frequent:
G1 Lack of Early Warning score or score requiring response
G4 Readmission within 30 days
G7 Complication of procedure or treatment
G8 Transfer to higher level of care
L4 Rising urea or creatinine
Trigger Tools
L1
4
L1
5
L9
L1
0
L1
1
L1
2
L1
3
L7
L8
L5
L6
L3
L4
L2
I2
M
1
M
2
M
3
M
4
M
5
L1
I1
S3
S2
G
1
G
2
G
3
G
4
G
5
G
6
G
7
G
8
S1
0
Adverse Event Triggers 2005 - 2007
18
16
14
12
10
8
6
4
2
Most frequent:
G7 Complication of procedure or treatment
G4 Readmission within 30 days
G2 Patient Fall
L12 Wound Infection
Trigger Tools
L1
4
L8
L9
L1
0
L1
1
L1
2
L1
3
L6
L7
L4
L5
L2
L3
I2
M
1
M
2
M
3
M
4
M
5
L1
I1
3
S
2
S
1
S
G
1
G
2
G
3
G
4
G
5
G
6
G
7
0
Events by Module 2005 - 2007
35
30
25
20
15
10
5
0
G
TOTAL
G General care
Trigger Tools
S
TOTAL
S Surgical care
I
TOTAL
I Intensive care
M
TOTAL
M Medication
L
TOTAL
L Lab tests
Degree of Harm Jan 2005 - July 2006
10
9
8
7
I
6
H
5
G
4
F
3
E
2
1
A
pr
il
M
ay
Ju
ne
Ju
A ly
S ug
ep us
te t
m
b
O er
ct
N ob
o v er
e
D mb
e
20 ce e r
06 mb
Ja e r
nu
Fe ar
br y
ua
r
M y
ar
ch
A
pr
il
M
ay
Ju
ne
Ju
ly
20
05
Ja
nu
Fe ar
br y
ua
r
M y
ar
ch
0
E Contributed to or resulted in temporary harm to the patient & required intervention
F Contributed to or resulted in temporary harm to the patient & required initial or prolonged
hospitalisation
G Contributed to or resulted in permanent patient harm
H Required intervention to sustain life
I Contributed to the patients death
Trigger Tools
Case Note Reviews –
Examples of Learning
• The amount of missing
information in records:
• Prescription sheets
• Nursing records
• TPR charts
Trigger Tools
Case Note Reviews –
Examples of Learning
Standard of documentation:
• Patient not documented
as discharged
• Illegible hand writing
• Events not documented
Trigger Tools
Trigger Tools - Summary
• Powerful Tool for identifying events/harm to
patients
• Time consuming
• Form is not intuitive BUT has been adapted
• Important to keep a record of the events
• The Global Tool is designed for adults
• Other tools available e.g. Adverse Drug Events,
ITU, Neonatal ICU, Outpatients, Peri-operative,
Mental health
Trigger Tools
Any Questions?
Next Steps?
Trigger Tools