Systems to review when using the IHI Global Trigger Tooll

Objective findings indicative of possible adverse event causation

Measuring Only Harm (MERP)
National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Errors.

  1. A Circumstances or events that have the capacity to cause error.
  2. B Any error that did not reach the patient.
  3. C An error that reached the patient but did not cause harm.
  4. D An error that reached the patient and required monitoring or intervention to confirm that it resulted in no harm to the patient.
  1. E Temporary harm to the patient and required intervention.
  2. F Temporary harm to the patient and reqquired initial or prolonged hospitalization.
  3. G Permanent patient harm.
  4. H Intervention required to sustain life.
  5. I Patient death.

Expand the Trigger Definitions

History

Conventional attempts to quantify adverse events have included voluntary incident reports, retrospective or concurrent record reviews (sometimes summplemented by bedside surveillance), and abstraction of events from observational databases. The concept of a trigger (or clue) to identify adverse events in the medical record was introduced by Jick in 1974, and refined by Classen by using electronic triggers with an integrated hospital information system.

Harm versus Error

The overall goal of improved safety in health care is to reduce patient injury or harm, which underscores the importance of distinguishing between errors and harm. Although detection and analysis of errors is important in understanding failure-prone aspects of health care delivery systems and designing strategies to prevent and mitigate these failures, there is special value in quantifying actual harm. Medical errors are failures in processes of care and, while they have the potential to be harmful, numerous reports have shown they are often not linked to the injury of the patient. Because events of harm are clear clinical outcomes, they are particularly likely to engage both clinicians and administrators in a thorough review of the system factors that led to the adverse event, with a clear focus on improving patient outcomes. By concentrating on the events actually experienced by patients, a hospital can begin to foster a culture of safety that shifts from individual blame for errors to comprehensive system redesign that reduces patient suffering. To address the clear need to quantify adverse patient outcomes, the Trigger Tool focuses on identification of harm or injury to the patient.

Definition of an Adverse Event

The Trigger Tool modifies the World Health Organization definition of adverse drug events, but goes beyond medications to include any event in association with medical care. The definition for harm is: unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death.

When a reviewer identifies a positive trigger, the reviewer should check other relevant portions of the record such as progress notes and orders that were documented in close proximity to the occurrence of the trigger. Documentation that the patient experienced harm from medical care should be present for an adverse event. For example, an INR level greater than 6 would be a positive trigger. The reviewer should look for documentation of bleeding or decreased hemoglobin with need for transfusion and other adverse events that can result from over-anticoagulation.

In determining whether an adverse event has occurred, consider that an adverse is defined as unintended harm to a patient from the viewpoint of the patient. There are several important aspects.

  • Would you be happy if the event happened to you? If the answer is no, then likely there was harm.
  • Was the event part of the natural progression of the disease process, or a complication of the treatment related to the disease process? The harm identified should be the result of some medical treatment. The decision is subjective at times and physician input will be critical.
  • Was the event an intended result of the care (eg a permanent scar from surgery)? If so, then this is not considered harm.
  • Psychological harm by definition has been excluded as an adverse event.

It is important to emphasize that reviewers may occasionally discover an adverse event without a trigger, while looking for triggers or other details. These events should be included when recording findings as {other}, regardless of whether a trigger led the reviewer to the adverse event.

An adverse event that is present on admission to the hospital should be included, provided that it meets the definition of being harm related to medical care. All such adverse events are counted because the measure is what the patient experienced, not what happened within the hospital. Field experience has shown that fewer than 10% of all harms that are detected by the Trigger Tool will be present on admission. It is useful to keep track of which events occurred outside the hospital so that this can be noted when reporting data. Such data may indicate an opportunity to collaborate with others — office practices, clinics, long-term care facilities — to improve patient safety, even if the events did not result from hospital care itself.

Commission versus Omission

The Trigger Tool focuses on and includes only those adverse events related to the active delivery of care (commission) and excludes, as much as possible, issues related to substandard care (omission). While adverse events due to omission of evidence-based treatments commonly occur and should be a focus in quality improvement efforts, they are not the focus of measurement with the Trigger Tool. During reviews, acts of omission may be noticed and can be referred to others as improvement opportunities.

For example, a patient not appropriately treated for hypertension who subsequently experienced a stroke certainly has had a medical catastrophe related to poor care, but would not be considered to have suffered an adverse event using the Trigger Tool definition because the event is related to omission of evidence-based care. However, a patient to whom anticoagulants were administered who subsequently suffered a stroke from an intra-cerebral bleed would be considered to have suffered an adverse event with the Trigger Tool because the use of the anticoagulant (commission) caused the event.

Preventability

The Trigger Tool includes all adverse events — that is, events which are unintended consequences of medical care, whether preventable or not. Reviewers should not attempt to determine preventability during a review. If an adverse event occurred it is, by definition, harm. The Tool is designed to be a method for measuring harm over time. If the definition of included events constantly changed depending on what was preventable, the measure over time would become meaningless.

Severity Ratings

The Trigger Tool adapts the classification from the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Errors. Although originally developed for categorizing medication errors, these definitions can be easily applied to any type of error or adverse event. The Tool counts only adverse events: harm to the patient, whether or not the result of an error. Accordingly, the tool excludes the categories A~D because these categories describe errors that do not cause harm.

These categories are not progressive (ie an event does not have to first meet the definition of E and F before it can be categorized as G). For category E, some intervention is required. For category H, experienced reviewers have found it helpful to define "lifesaving intervention" as that which must be provided in one hour or less in order to prevent death. For example, a patient with a surgical site infection requires antibiotic treatment and one could argue that failure to provide it could lead to sepsis and death. While this may be true, it is unlikely that the antibiotic would need to be provided within one hour to prevent death. However, a patient who develops respiratory depression and arrest from a narcotic requires immediate intervention, such as non-invasive or invasive ventilation; this would be an intervention required to sustain life, even if it was only needed for a few hours. For category I, the event needs only to be contributory to the death.

Trigger Selection

IHI developed the triggers by reviewing the literature on adverse events in various areas of the hospital. IHI then tested these prioritized triggers in hundreds of hospitals. Modules are added, deleted, and adjusted over time to reflect changes in treatments and types of adverse events being identified in the field.

References:
  1. ​​​​Institute for Healthcare Improvement. IHI Global Trigger Tool for Measuring Adverse Events. www.ihi.org/resources/…
  2. ​​​​Institute for Healthcare Improvement. IHI Surgical Trigger Tool for Measuring Peri-operative Adverse Events. www.ihi.org/resources/…
  3. ​​​​Institute for Healthcare Improvement. Trigger Tool for Measuring Adverse Drug Events in a Mental Health Setting. www.ihi.org/resources/…