Global Trigger Tool

The Global Trigger Tool Workshop

March 2008

Presenters: Annette Bartley & Jonathon Gray

Global Trigger Tool

Session overview• Background and context • Brief presentations from mentor sites

– Julie Ward-Jones– Cathie Steele– Kate Hooton

• 15 minute round table discussion – What are you finding & learning?– Where is the harm in your organisation?

• Report out• Next steps

Global Trigger Tool

Reliability in Healthcare• Healthcare is a high hazard industry• Approximately 10% (900,000) of patients admitted to

hospital experience a patient safety incident• 72,000 of these incidents/adverse events contribute

to the death of patients• Over 2,000,000 reported patient safety incidents

/adverse events (NPSA, 2008)• Many go unrecognised / hidden /accepted

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Risk Culture• Reactive approach• Existing good practice • Focus on mitigation• Lots of information but where is the improvement?• Root Cause Analysis • Delays in closing the loop • Failing to identify many adverse events• Disconnected from clinical practice

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Do we really understand where our ‘harm’ lies?

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Patient Safety – The Facts

One of the main causes of death:1. Cardiovascular Disease

2. Cancer

3. Respiratory Disease

4. Adverse Events

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A Safety Culture in Healthcare

• People do not intend to commit errors• Accidents are rarely due to single errors and are often

the end product of multiple factors• Just Culture• Less focus needs to placed on the individual and

more on the organisation• What does this tell us about ‘our’ system• Safety is everyone’s responsibility

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Campaign aims

• Save 1000 lives and reduce 50,000 episodes of harm by April 2010

• How will we know that the changes we implement are an improvement?

• We need to be able to understand where harm lies first

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IHI Global Trigger Tool (GTT)

• Currently used in hundreds of hospitals

throughout the world

• Undergoing a rigorous comparison to

other methodologies

• Incorporates identification of events

across an organisation

Global Trigger Tool

Campaign aims

• Save 1000 lives and reduce 50,000 episodes of harm by April 2010

• How will we know that the changes we implement are an improvement?

• We need to be able to understand where harm lies first

Global Trigger Tool

Why Use Trigger Tools?• Traditional reporting of errors, incidents, or

events does not reliably occur in the best of cultures in healthcare

• Voluntary methods frequently underestimate events and concentrate on what is interpreted as being preventable

• Easily identifies events without complex technology

• Can be integrated into a good sampling methodology

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• Establishes a baseline of adverse events.• Types of adverse events can be catalogued and prioritized.• Resources can be focused on those eventscausing the greatest harm.• Effect of interventions can be monitored whenadverse event rate is measured over time.

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• Natural extension from the area-specific tools• Uses multiple modules of triggers• Gathers events from the whole hospital• Establishes a global harm measure for the hospital• Resource friendly and no dependency on high tech

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Basic Principles

• Review with a trained team.• Select a small, random sample.• Look for the presence of triggers only.• Determine whether harm occurred from perspective of the patient.• Assign category of harm.• Tabulate data and track over time.

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Key Points

• Only allow a maximum of 20 minute per review• Look for triggers only …don’t read the entire record.• A a positive trigger is not necessarily an adverse event.• Determine and assign severity of harm rating based on the perspective of patient: “ Did I suffer harm?”•BE CONSISTENT

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Adverse events are best defined from the viewpoint of the patient

Would I be happy if the event happened to me?

An adverse event is harm to the patient

from the viewpoint of the patient

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A Representative SamplePopulation A representative sample

A properly selected random sample will produce results very similar to the results you would get if you collected data on the entire population.

Negative Outcome Positive Outcome

A negatively biased sample

A positively biased sample

AC B

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Drilling Down with the Data

• Modules within the Trigger Tool can be used for focused reviews.

– Use the Medications Module to track ADEs.– This can be reported as an additional measure.

• Drill down when you see areas of concern to monitor for specific improvement.

– Example: Use those triggers related to adverseevents for anticoagulants to track ADEs fromthese medications while working to improve.

• Drill-down measures will improve before theoverall adverse event rate.

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How it is Actually Done 1. Select 2 reviewers plus a physician adjudicator.

2. Choose 20 random charts

3. Set your timer for 20 minutes

4. Review the coding summary (look for e-codes and obvious events)

5. Review the discharge summary

6. Review the blood/ lab

7. Review the x-ray reports

8. Review the procedure notes

9. Any time left over, review nurse notes

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Events per 1,000 Days

Events/1000 Days

0

20

40

60

80

100

120

DateJune-Sept 04

Eve

nts

/100

0 da

ys

Events/1000 days

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Summary• Triggers are merely tools which help you locate adverse

events • Offer organisations the ability to measure harm in a simple

and cost effective manner.• Measuring yourself against yourself• This data can then be used to create “will” in your

organization for change and enables you to understand unique problems that you are facing.

• Primary care settings need to be able to understand where their harm lies in order to focus improvement efforts

• Challenge is to make this work for Trusts & LHBs , primary care

• Whole systems review

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Accepting the Harm Burden Adverse Event vs. Error• “Error” definition bears upon concept of preventability,

and is therefore process-focused• “Adverse event” describes harm to the patient, and is

thus outcome focused• Relationship between errors and adverse events:

Errors

Adverse Events

Mortality

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Adverse EventsNew (Harm) Vs. Old (Errors)

• Concentrates less on peoplemore on systems• Looks at all unintendedresults• Makes measurement easier• Concentrates on harm andthose errors that causeharm

• Errors are the focus of discussion and solutions• Tends to focus only onthose results felt to berelated to error, ignoresother events• Requires judgement• Human found responsiblefor most of the errors

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IHI Harm Study1) To develop and deploy a standardized record review

methodology for measuring harm due to care in hospitalized patients

2) To use this methodology to estimate and track the level of harm in the United States over time, by applying this record review methodology in US organisations.

3) Time series analysis will be used to rigorously measure trends over time.

4) As knowledge in the field evolves, IHI expects that this methodology will be refined and supplemented with additional data sources.

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Severity of harm

All injuries due to medical care are classified as categories “E” though “I” as follows:

E. Injuries that require treatment or monitoring, but not longer hospital stays (such as most cases of phlebitis caused by intravenous catheters)F. Injuries that are temporary, but extend hospital stay (such as a pressure ulcer)G. Injuries that lead to permanent harm (such as a large scar from an infection)H. Injuries that require immediate intervention to save life (such as a reversible, but potentially lethal, medication overdose)I. Injuries that cause or contribute to death (such as fatal sepsis from a catheter infection)

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Events per 1,000 Days

Events/1000 Days

0

20

40

60

80

100

120

DateJune-Sept 04

Ev

en

ts/1

00

0 d

ay

s

Events/1000 days

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Moving your dot

• It won’t happen if…– You quietly contemplate the findings and

keep the information to yourselves – You only use the info to report

• It requires a deeper understanding of harm

• And… appropriate & timely action

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Capturing the learning • Note the issues on the template during

reviews

• Adapt the template to suit your needs

• Feedback the issues and trend through the most appropriate forum

• Monitor adverse events rate

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Closing the loop

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Progress to date

• Documentation sent out• Conference calls set up to build upon the

information • Repeating and clarifying key aspects• Faculty support• Learning from SPI sites

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MENTOR SITES

• Julie Ward–Jones– Service Improvement Facilitator NEWT

• Cathie Steele- – Head of Clinical Governance Cardiff & Vale

• Kate Hooton- – Head of Clinical Governance Gwent

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Round table discussion

• What progress have you made?

• What are you learning?

• Where is the harm in your organisation?

• How will you close the loop?

• Report out –by teams

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Panel discussion

• Questions for the panel?

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Key learning

• The global trigger tool gives you the ability to measure harm in a simple and cost effective manor.

• Build it into existing roles (audit, risk, safety)• Remember the most important information deals with

the adverse event you find and not the “trigger”. Triggers are tools to find adverse event.

• This data can be used to create “will” in your organization for change and allows you to understand unique problems that you are facing.

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Summary• Aim so far was to build the will

• Measurement for learning vs measurement for judgment

• Understand harm and identify where there are opportunities for improvement

• Make hospitals safer for patients

• Exciting times ahead…

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Next steps

• Complete the retrospective review of case notes using the tool

• 6 month baseline-Oct 07-April 08

• Set up feedback systems to learn from these event

• Get the dots plotted

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Contact details

• Annette.bartley@cd-tr.wales.nhs.uk

• jgray@ihi.org