Global trigger tool

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A global trigger tool is an interaction model in a clinical decision support system that helps identify adverse patient events.

Introduction

Adverse events in healthcare may be occurring at an even greater rate than documented in earlier studies. In 1991, the Harvard Medical Practice Study (1,2), which was foundational to the Institute of Medicine report To Err is Human,(3) reported that “3.7% of patients had injuries and that negligent care was responsible for 28% of them.”

In November 2010, the OIG (Office of the Inspector General) reported that currently accepted methods of identifying error and patient harm may be insufficient.(4) A study of a representative sample of 750 Medicare beneficiaries discharged during October 2008 was conducted, using physician reviewers. An estimated 13.5% of patients in this study experienced an adverse event (a National Quality Forum serious reportable event, a Medicare reportable Hospital Acquired Condition or an event resulting in the 4 most serious categories of harm on the NCC MERP Index (5)) during their hospital stays. An additional 13.5% of Medicare beneficiaries experienced temporary harm from events that occurred during their hospital stays.

A previous OIG study (6) evaluated five methods of screening for events. This screening methodology included “nurse reviews of medical records, interviews of Medicare beneficiaries, two types of billing data analysis, and reviews of internal hospital incident reports.” A second stage included physician reviews of “flagged” records.

This March 2010 OIG study looked at “the usefulness of selected methods for identifying events that harm Medicare beneficiaries.” Billing data and hospitals’ internal incident reporting data both were considered inaccurate or unreliable. Findings and recommendations of the study documented that effective identification of adverse events requires nurse or physician review, and that other screening methods “identify far fewer events.”

An even more recent study, published by Classen and colleagues, in April, 2011,(7) and using the Institute for Healthcare Improvement’s ‘Global Trigger Tool’ found that, “Overall, adverse events occurred in 33.2% of hospital admissions (range:29-36%) or 91 events per 1,000 patient days (range: 89-106).”

Methods to avoid errors

Common methods to identify error and harm (internal/voluntary reporting, AHRQ Patient Safety Indicators analysis through billing data) were found by both the OIG study and the Classen study to miss the mark in terms of identifying adverse events and harm to patients.

OIG recommended to CMS (Center for Medicare and Medicaid Services) and AHRQ (Agency for Healthcare Research and Quality) that the search for medical error/events become part of any other record review. CMS should assure that “hospitals code claims accurately and completely to allow for identification of hospital-acquired conditions…” In addition, CMS should “provide interpretive guidelines for State survey agencies to assess hospital compliance with requirements to track and monitor adverse events.” And further, AHRQ should [disseminate information] that hospital incident reporting “may be insufficient to provide needed information about events…” (8)

Classen, et al, affirmed the OIG findings with their study, which found that of three methods to identify adverse events, the Institute of Medicine’s Global Trigger Tool was more sensitive (finding more true positives) and more specific (able to identify those who had not experienced an adverse event). Other methods “fail to detect more than 90% of the adverse events that occur among hospitalized patients.” (9)

Methodology

All of this leads to the inevitable consideration of whether the “Global Trigger Tool” methodology, which looks for “triggers” (such as the administration of narcotic antagonists such as Narcan, to then drill deeper to determine whether the drug was needed due to medical error or to appropriate presenting conditions), could be automated to screen the clinical record for such “flags” and thus make the process more efficient.

Kaiser Permanente reported on their efforts to do just that at the AHRQ Annual Conference in 2010. (10) Kaiser piloted an Automated Adverse Event Monitoring Program (AAEMP), utilizing the IHI Global Trigger Tool as a framework. After pilot implementation, Kaiser Permanente found that the AAEMP “allows detection of triggers in near real time” as compared to retrospective review and identification which is “well after the fact.” In addition, the automated system allows search of all hospitalized patients, instead of just a sample, and allows for close surveillance…for rapid detection and prevention or mitigation of harm.

It appears that an automated solution to the surveillance of indicators of adverse events and harm attributable to errors of omission and commission is possible, and meets the requirements of oversight entities, as well as practice settings of all sizes.

A consideration of an EHR for an enterprise should include the capability to address this important aspect of the complexity of delivery of healthcare today.

References

  1. Brennan T, et al; Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study I, N Engl J Med 1991:324:370-6 http://www.nejm.org/doi/full/10.1056/NEJM199102073240604
  2. Leape LL, et al; The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II, N Engl J Med 1991: 324:377-84 http://www.nejm.org/doi/full/10.1056/NEJM199102073240605
  3. Kohn LT, Corrigan JM, Donaldson MS, Ed., To Err is Human: Building a Safer Health System, 2000, National Academy Press, Washington DC http://www.nap.edu/openbook.php?record_id=9728
  4. Office of the Inspector General (OIG), Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, November 2010, OEI-06-09-00090, http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf
  5. National Coordinating Council for Medication Error Reporting and Prevention: http://www.nccmerp.org/medErrorCatIndex.html
  6. Office of the Inspector General (OIG), Adverse Events in Hospitals: Methods for Identifying Events, March 2010 OEI-06-08-00221, http://oig.hhs.gov/oei/reports/oei-06-08-00221.pdf
  7. Classen DC, et al: ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured, Health Affairs 30, NO. 4 (2011) 581-589, downloaded from content.healthaffairs.org by Health Affairs on May 14, 2011 at Oregon Health SCI Univ L593
  8. Office of the Inspector General (OIG), OEI-06-08-00221, p iii
  9. Classen DC, et al: p 586.
  10. Snow D, Kaiser Permanente Experience with Automating the IHI Global Trigger Tool: Slide Presentation from the AHRQ 2010 Annual Conference, September 29, 2010

Submitted by Terri Camp;