Anne Matlow MD FRCPC Medical Director, Patient Safety Hospital for Sick Children, Toronto
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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
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DISCLOSURE
I am Canadian
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And I won’t rub it in!!!
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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
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Trigger tool
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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.
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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%
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1. Unplanned admission pre2. Unplanned readmit within
12 months3. Hospital incurred injury4. Adverse drug event5. Unplanned transfer to ICU6. Unplanned transfer to
another acute care hosp7. Unplanned return to OR8. Unplanned removal, injury
or repair intra-operatively9. Other patient complications
10.New neurological deficit11.Unexpected death12. Inappropriate discharge home13.Cardiac/ resp arrest / low
APGAR score14. Injury related to delivery or
abortion15.Hospital acquired infection/
sepsis16.Documented dissatisfaction
with care17.Documentation or
correspondence re litigation18.Any other undesirable
outcomes
SCREENING/EXPLICIT CRITERIA
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Detecting Adverse Events
Method AE/1000 admissions
Incident Reports (2-8%) 5Retrospective Chart Review 30Stimulated Voluntary Reports 30Automated Flags 55*Daily chart review 85Automated Flags and Daily review 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
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• 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
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Voluntary reporting and computerized surveillance not as good as chart review
Manual Chart Manual Chart ReviewReview
367
Computerized Computerized SurveillanceSurveillance
331 205
20
Voluntary Voluntary ReportingReporting
Classen DC, Pestotnik S. Evans S et al. Computerized surveillance of adverse drug events in hospitalized patients. JAMA. 1991;226:2847
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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
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Trigger Tool 2 stage ReviewTrigger Tool 2 stage Review
TRIGGERS ADVERSE EVENTS
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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)
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Adverse Events in the NICU Sharek et al. Pediatrics. 2006:118:1332-1340
n=55474 per 100 admissions of which 56% preventable
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Incidence of Adverse Events and Negligence in Hospitalized Patients
Brennan NEJM 1991
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Adverse events and preventable adverse events in children Woods Peds 2005:115:155
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Adverse events and preventable adverse events in children Woods D. Pediatrics. 2005 Jan;115:155-60.
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Quality in Australian Health Care StudyWilson Med J Aust 1995
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Diagnostic errors are commoncause of adverse events
De Vries QSHC 2008; Soop IJQHC 2009
AE rate DiagnosticNY 1984 3.7% 7%Utah/Col 1992 2.9% 6.9%Australia 1992 16.6% 13.3%NZ 1998 13.1% 8%UK 1999 10.8% 4.2%Canada 2001 7.5% 10.6%Sweden 2003 14.2% 11.3%
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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
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CAN TRIGGER TOOLS HELP US IDENTIFY DIAGNOSTIC
ERROR?
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Sensitivity and Specificity of the Canadian Paediatric Trigger Tool
Adverse Event
Trigger Yes No Total
Yes 78 283 361 (60%)
No 11 219 230
Total 89 (15%) 502 591
89 patients experienced at least 1 AE
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Clinical Care Process vs #AE
Surgical 50
Medical Procedure 16
Diagnostic 14
Clinical management 10
Drug/Fluid 10
Fractures 1
System Issue 1
Other
Total number of AEs
21
123
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Clinical Care Process vs #AE
Surgical 50
Medical Procedure 16
Diagnostic 14
Clinical management 10
Drug/Fluid 10
Fractures 1
System Issue 1
Other
Total number of AEs
21
123
11.4% of adverse events were diagnostic
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Distribution of AEs by Age Category
Surg Med Proc
Diag Clin Man
D/ FL Other
0-28 d 18 11 4 9 2 12
29- 365 d 11 2 4 0 1 9
366 d-
5 yr14 0 3 0 6 1
>5 yr 7 3 3 1 1 1
Total # AEs
50 16 14 10 10 23
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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.
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CAN TRIGGER TOOLS HELP US IDENTIFY DIAGNOSTIC
ERROR?
METHODOLOGY DEPENDENT
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CPTT
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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?
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FOCUSING ON DIAGNOSTIC ERROR WILL FILL IN A BLANK
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