(adverse events per 100 inpatient days)
Table 1. Adverse Events by Severity
| Grade | IHI | CCH |
|---|---|---|
| E | 72% | 75% |
| F | 10% | 15% |
| G | 8% | 7% |
| H | 8% | 0% |
| I | 2% | 2% |
Results from our first year of experience with this methodology are shown in Table 1 and Table 2. A total of 170 medical records were reviewed after being selected at random according to the protocol in the IHI White Paper. Table 1 shows that our results were comparable to the IHI data, except for category H. This reflects the transitory nature of this event, and the lack of documentation in the medical record. During this period, we were unable to find a single example of this.
Table 2. Adverse Event Indicators
| Indicator | Numerator | Denominator | Rate |
|---|---|---|---|
| Trigger events/chart | 185 | 170 | 1.09% |
| Adverse events/chart | 97 | 170 | 57.0% |
| Sentinel events/chart | 2 | 170 | 1.2% |
| Ratio of Trigger Events to AE | 185 | 97 | 1.9% |
| AE without Trigger Event | 2 | 13 | 15.4% |
| Ratio of Sentinel Events to AE | 13 | 97 | 13.4 |
Table 2 shows some indicators derived from the data we retrieved from the 170 medical records. This table shows that nearly every chart had a trigger event (1.09%), and that an adverse event occurred approximately once for every two charts (57%). Of concern is the relatively high incidence of adverse events found in charts without a trigger, reflecting the incomplete documentation common at that time.
References
- Talbot AR et al. Measuring Hospital Safety — Using the Global Trigger Tool to Identify Adverse Events YiLiao PinZhi 2010; 4(2): 93-8. [in Chinese] 張旭東(Hsu-Tung Chang) ； 陶阿倫(Alan-Ronald Talbot) A Great Way to Improve Healthcare Safety-Using Medical Record Review as the Tool 醫療安全偵測之利器－以病歷調查為工具 病歷資訊管理 ； 12卷2期 (2013 / 12 / 01) ， P1 - 12 Abstract 意外事件通報強調自願性、無懲罰及匿名性。但由台灣病人安全通報系統發現醫院所通報的意外事件，嚴重度輕微或無傷害佔大多數；IHI報告中也發現，僅有10%～20%的錯誤會通報出來，其中有90%～95%是無傷害事件。因此，醫院需要有效的方法找出造成病人傷害的事件。採用IHI全面性觸發工具審查病歷偵測醫療不良事件：一、審查符合以下條件的病歷：出院超過30天、完成病歷書寫、住院超過1天及年齡18歲以上。二、每兩週隨機抽樣，完成10本病歷分析。三、組成意外事件病歷審查小組，依據NCC MERP之嚴重度等級和IHI全面性觸發工具調查病歷中之醫療不良事件，並進行審查一致性訓練。病歷審查成員間審核一致性評估由85%提升至95%。至2012年12月31日共計審查960本病歷，不良事件發生率平均為43.1%，嚴重度E：42%、F：45%、G：5%、H：0%、I：8%。不良事件發生率平均值由2009年的千分之74.7逐年下降至千分之46.1（2010年）、千分之36.7（2011年）、千分之24.2（2012年）。運用全面性觸發工具審查病歷，可以成功的偵測到未通報之醫療不良事件，並進行原因探討且追蹤系統改善，可有效降低不良事件發生率，提昇醫院安全。 In reporting incidental events we emphasize on three things, i.e. on a voluntary basis, no penalty to be involved, and to be anonymous. However, from what we've learned in the existing Taiwan Patient Safety Reporting System that the great majority of the events reported through the system were either of little harm or no harm at all. A recent report by the Institute of Healthcare Improvement (IHI) on this very topic also indicated that only 10%~20% of all errors that presumably did take place were reported, of which 90%~95% turned out to be quite harmless. Therefore, the hospital needs a much more effective way to find out events causing harm to the patients.In this study we adopted the IHI Global Trigger Tool to look into our patient health records to monitor the so-called adverse events. The process included: 1. picking out records meeting the following criteria: the patient has been released by the hospital more than 30 days, the health record has been completed in writing, the patient stayed at the hospital for more than one day, and the patient was 18 or older; 2. in every two weeks we selected in random 10 such health records and completed the analysis; and 3. organizing an Incident in Health Record Review Taskforce and utilized the NCC NERP Severity Scale and the IHI Global Trigger Tool to find out adverse events in those records. At the same time, training was conducted to standardize the review procedures to better consistency.During the study we found the consistency of the reviews made by our taskforce members was enhanced from 85% to 95%. From January 2009 to December 31, 2012, we reviewed a total of 960 medical records, and the finding showed the average rate of adverse events/1,000 patient-days was 43.1 and decreasing annually from 74.7 (2009), 46.1 (2010), 36.7 (2011) to 24.2 (2012). Categories of harm are E: 42%; F: 45%; G: 5%; H: 0%; I: 9%.In conclusion, we found using the IHI global trigger tool in our health record review did help us successfully detect adverse events that evaded in our old system. This allowed us to look into the causes to better our tracking system, and effectively lowered down the occurrence rate of adverse events and improve the safety of the hospital as well. ********************** 陶阿倫(Alan-Ronald Talbot) ； 吳秀玲(Hsiu-Ling Wu) Using IHI Global Trigger Tool to Measure Hospital Safety 運用IHI Global Trigger Tool衡量醫院安全 醫院雙月刊 ； 51卷6期 (2018 / 12 / 31) ， P69 - 76 Abstract 運用Institute of Healthcare Improvement, IHI (www.IHI.org)，所發展的Global Trigger Tool for Measuring Adverse Events［全面性觸發工具衡量不良事件］的客觀方法，來衡量醫院的安全。自2009年到2014年運用IHI Trigger tool為篩選工具，由受訓後的醫師、藥師、護理師及管理師共同審查病歷紀錄。對於不良事件的發生率發現不良事件發生率、每本病歷不良事件件數、警訊事件發生率結果，都逐年呈現明顯下降趨勢。客觀數據使我們能夠成功記錄醫院安全性已得到改善。並且在項目中發現的不良事件隨後進行了深入調查。目標是創建一個以患者安全為中心的醫療環境。 The Institute of Healthcare Improvement, IHI (www.IHI.org), developed the Global Trigger Tool for Measuring Adverse Events, an objective method to measure hospital safety. From 2009 to 2014, The IHI Trigger tool was used as a screening tool, and medical records were reviewed by trained physicians, pharmacists, nurses, and administrators for the incidence of adverse events. It was found that the incidence of adverse events, the number of adverse events per case, and the incidence of warning events all showed a significant downward trend year by year. The objective data allow us to successfully document that the hospital safety has improved. Adverse events discovered in the project were followed up by in-depth investigation. The goal is to create a medical care environment centered on patient safety. ********************** 吳秀玲(Hsiu-Ling Wu) ； 陶阿倫(Alan-Ronald Talbot) ； 吳怡靜(Yi-Ching Wu) Improve incident management effectiveness 運用資訊系統提高意外事件管理成效 醫院雙月刊 ； 51卷2期 (2018 / 04 / 30) ， P9 - 16 Abstract 近幾年醫院不斷鼓勵員工執行意外事件通報，至2015年年底統計發現尚有8.5%（未簽核件數／該年度通報總件數）的意外事件件數主管未簽核，這些件數其中超過100天以上的佔55.7%，於是進行PDSA (Plan-Do-Study-Act)品質管理循環。由資訊部列出報表、設計系統自動發Email通知、提報規章委員會，載明應於規定的工作天數內完成簽核、另外件數≧3件或日數超過100天以上者，再由專人用電話聯絡，了解原因並協助完成。經一週後發現簽核未完成率由9%降為3%、其中超過100天以上的由60%降為12%，未達期望目標。故再次深入探討得知：66%尚在評估改善成效、18%職務異動跨院區無法完成、16%不孰悉簽核路徑，於是未進入系統完成簽核。針對未達期望目標的原因，把焦點定在分析、處理而不只是為簽而簽。運用資訊化管理、專人協助執行改善，再次評估發現原本3%待簽核的意外事件，一週後餘1.8%、超過100天以上0%。之後將此作業設定標準化，簽核逾7天未完成者，每週一系統發通知給醫品部，追蹤至今近2年維持每週10件以下，有效改善事件通報簽核逾時未簽核的情形。 In recent years, employees are constantly encouraged to carry out notification of accidents. However, as of the end of 2015, 8.5% of the number of unidentified accidents (not signed number/ the total number of notifications for the year) were found, of which over 100 days Accounting for 55.7% of the total, so as to conduct a PDSA (Plan-Do-Study-Act) quality management cycle. Information Department, first list the statements designed to be automatically sent by Email notification and report to the rules and regulations set forth in the working days should be completed within the required number of sign; the other three or more days more than 100 days by persons Contact by phone again to find out why and help with it. After a week, it was found that the unfinished rate of sign-off was reduced from 9% to 3%, of which over 60% was reduced to 12% over 100 days, failing to achieve the expected target. Further in-depth study revealed that: 66% are still assessing the effectiveness of the improvement, 18% of job changes across the hospital area can not be completed, 16% do not know where to sign the path. So did not enter the system to complete the sign. For less than the expected goal of the reasons, the focus on analysis, processing and not just sign. Using information management, assisted by individuals to implement improvements, reevaluation found that the original 3% pending the accident, 1.8% after one week, 0% over 100 days. After this standardization of job settings, sign off more than seven days were not completed, the system sent a weekly notification to the Medical Quality and Safety Department, Track nearly 2 years now maintain 10 or less per week, effectively improve the notification of the event out of time situation.
- Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2009. www.ihi.org/resources/