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Health Serv Res. 2014 Oct;49(5):1407-25. doi: 10.1111/1475-6773.12163. Epub 2014 Mar 13.

Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval.

Author information

1
Office of the Chief Quality Officer, Baylor Health Care System, Baylor Scott and White Health, 8080 N. Central Expressway, Suite 500, Dallas, TX 75206.

Abstract

OBJECTIVE:

To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.

STUDY SETTING:

Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.

STUDY DESIGN:

We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.

DATA COLLECTION:

Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs).

PRINCIPAL FINDINGS:

Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs.

CONCLUSIONS:

AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

KEYWORDS:

Adverse events; Global Trigger Tool

Comment in

PMID:
24628436
PMCID:
PMC4213042
DOI:
10.1111/1475-6773.12163
[Indexed for MEDLINE]
Free PMC Article

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