Validation of triggers and development of a pediatric trigger tool to identify adverse events

BMC Health Services Research

Karin Pukk Härenstam³  Carina Berglund¹  Urban Nylén¹  Britt-Marie Ygge²  Per Nydert⁵  Synnöve Lindemalm⁵  Maria Unbeck⁴ 

[1]SALAR (Swedish Association of Local Authorities and Regions), Stockholm, 118 82, Sweden

[2]Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, 171 77, Sweden

[3]Medical Management Centre, Karolinska Institutet, Stockholm, 171 77, Sweden

[4]Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, 182 88, Sweden

[5]Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, 171 77, Sweden

关键词: Safety;    Pediatric care;    Retrospective record review;    Trigger tool;    Adverse event;   

Others  :  1089886
DOI  :  10.1186/s12913-014-0655-5

 received in 2014-06-27, accepted in 2014-12-11,  发布年份 2014

【 摘 要 】

Background

Little is known about adverse events (AEs) in pediatric patients. Record review is a common methodology for identifying AEs, but in pediatrics the record review tools generally have limited focus. The aim of the present study was to develop a broadly applicable record review tool to identify AEs in pediatric inpatients.

Methods

Using a broad literature review and expert opinion with a modified Delphi process, a pediatric trigger tool with 88 triggers, definitions, and descriptions including AE preventability decision support was developed and tested in a random sample of 600 hospitalized pediatric patients admitted in 2010 to a single university children’s hospital. Four registered nurse-physician teams performed complete two-stage retrospective reviews of 150 records each from either neonatal, surgical/orthopedic, medicine, or emergency medicine units.

Results

Registered nurse review identified 296 of 600 records with triggers indicating potential AEs. Records (n = 121) with only false positive triggers not indicating any potential AEs were not forwarded to the next review stage. On subsequent physician review, 204 (34.0%) of patients were found to have had 563 AEs, range 1–27 AEs/patient. A total of 442 preventable AEs were found in 161 patients (26.8%), range 1–22. Overall, triggers were found 3,598 times in 417 (69.5%) records, with a mean of 6 (median 1, range 0–176) triggers per patient. The overall positive predictive value of the triggers was 22.9%, (range 0.0-100.0%). The final pediatric trigger tool, developed with a second Delphi round, required 29 triggers.

Conclusions

AEs are common in pediatric patients and most are preventable. The main contributions of this study are to further develop and adapt trigger definitions, including AE preventability decision support, to introduce new triggers in pediatric care, as well as to apply pediatric triggers in different clinical specialties. Our findings resulted in a national pediatric trigger tool, and might also be adapted internationally. The pediatric trigger tool can help healthcare organizations to measure and analyze the AEs occurring in hospitalized children in order to improve patient safety.

【 授权许可】

   
2014 Unbeck et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC: 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood) 2011, 30:581-589.
• [2]Naessens JM, Campbell CR, Huddleston JM, Berg BP, Lefante JJ, Williams AR, Culbertson RA: A comparison of hospital adverse events identified by three widely used detection methods. Int J Qual Health Care 2009, 21:301-307.
• [3]Olsen S, Neale G, Schwab K, Psaila B, Patel T, Chapman EJ, Vincent C: Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Qual Saf Health Care 2007, 16:40-44.
• [4]Sari AB, Sheldon TA, Cracknell A, Turnbull A: Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007, 334:79.
• [5]Unbeck M, Muren O, Lillkrona U: Identification of adverse events at an orthopedics department in Sweden. Acta Orthop 2008, 79:396-403.
• [6]Agarwal S, Classen D, Larsen G, Tofil NM, Hayes LW, Sullivan JE, Storgion SA, Coopes BJ, Craig V, Jaderlund C, Bisarya H, Parast L, Sharek P: Prevalence of adverse events in pediatric intensive care units in the United States. Pediatr Crit Care Med 2010, 11:568-578.
• [7]Kirkendall ES, Kloppenborg E, Papp J, White D, Frese C, Hacker D, Schoettker PJ, Muething S, Kotagal U: Measuring adverse events and levels of harm in pediatric inpatients with the global trigger tool. Pediatrics 2012, 130:e1206-e1214.
• [8]Larsen GY, Donaldson AE, Parker HB, Grant MJ: Preventable harm occurring to critically ill children. Pediatr Crit Care Med 2007, 8:331-336.
• [9]Matlow AG, Baker GR, Flintoft V, Cochrane D, Coffey M, Cohen E, Cronin CM, Damignani R, Dube R, Galbraith R, Hartfield D, Newhook LA, Nijssen-Jordan C: Adverse events among children in Canadian hospitals: the Canadian paediatric adverse events study. CMAJ 2012, 184:E709-E718.
• [10]Matlow AG, Cronin CM, Flintoft V, Nijssen-Jordan C, Fleming M, Brady-Fryer B, Hiltz MA, Orrbine E, Baker GR: Description of the development and validation of the Canadian paediatric trigger tool. BMJ Qual Saf 2011, 20:416-423.
• [11]Woods D, Thomas E, Holl J, Altman S, Brennan T: Adverse events and preventable adverse events in children. Pediatrics 2005, 115:155-160.
• [12]Woods DM, Holl JL, Klein JD, Thomas EJ: Patient safety problems in adolescent medical care. J Adolesc Health 2006, 38:5-12.
• [13]Griffin F, Resar R: IHI global trigger tool for measuring adverse events (second edition). 2nd edition. Institute for Healthcare Improvement, Cambridge, Massachusetts; 2009.
• [14]Burch KJ: Using a trigger tool to assess adverse drug events in a Children's rehabilitation hospital. J Pediatr Pharmacol Ther JPPT Off J PPAG 2011, 16:204-209.
• [15]Lander L, Roberson DW, Plummer KM, Forbes PW, Healy GB, Shah RK: A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology. Otolaryngol Head Neck Surg 2010, 143:480-486.
• [16]Sharek PJ, Horbar JD, Mason W, Bisarya H, Thurm CW, Suresh G, Gray JE, Edwards WH, Goldmann D, Classen D: Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in north american NICUs. Pediatrics 2006, 118:1332-1340.
• [17]Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ: Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics 2008, 121:e927-e935.
• [18]Chapman SM, Fitzsimons J, Davey N, Lachman P: Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the paediatric trigger tool. BMJ Open 2014, 4:e005066.
• [19]Hasson F, Keeney S, McKenna H: Research guidelines for the Delphi survey technique. J Adv Nurs 2000, 32:1008-1015.
• [20]Unbeck M, Schildmeijer K, Henriksson P, Jurgensen U, Muren O, Nilsson L, Pukk Harenstam K: Is detection of adverse events affected by record review methodology? an evaluation of the "harvard medical practice study" method and the "global trigger tool". Patient Saf Surg 2013, 7:10. BioMed Central Full Text
• [21]SFS 2010:659: Patient Safety Act. Riksdagen, Stockholm; 2010.
• [22]Structured record review to identify and measure occurrence of adverse events in health care according to the method Global Trigger Tool [handbook in Swedish]. Stockholm: Kommentus förlag; 2008.
• [23]Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH: Incidence of adverse events and negligence in hospitalized patients. Results Harv Med Pract Study I N Engl J Med 1991, 324:370-376.
• [24]Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD: The quality in Australian health care study. Med J Aust 1995, 163:458-471.
• [25]National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). NCC MERP Index for Categorizing Medication Errors [http://www.nccmerp.org/medErrorCatIndex.html]
• [26]Marker based record review to identify and measure harm in health care: [handbook in Swedish]. Stockholm: Sveriges kommuner och landsting; 2012.
• [27]Solevag AL, Nakstad B: Utility of a paediatric trigger tool in a Norwegian department of paediatric and adolescent medicine. BMJ Open 2014, 4:e005011.
• [28]Brenner S, Detz A, Lopez A, Horton C, Sarkar U: Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients. BMJ Qual Saf 2012, 21:670-675.
• [29]Carnevali L, Krug B, Amant F, Van Pee D, Gerard V, de Bethune X, Spinewine A: Performance of the adverse drug event trigger tool and the global trigger tool for identifying adverse drug events: experience in a Belgian hospital. Ann Pharmacother 2013, 47:1414-1419.
• [30]Resar RK, Rozich JD, Simmonds T, Haraden CR: A trigger tool to identify adverse events in the intensive care unit. Jt Comm J Qual Patient Saf 2006, 32:585-590.
• [31]Rosen AK, Mull HJ, Kaafarani H, Nebeker J, Shimada S, Helwig A, Nordberg B, Long B, Savitz LA, Shanahan CW, Itani K: Applying trigger tools to detect adverse events associated with outpatient surgery. J Patient Saf 2011, 7(1):45-59.
• [32]Sari B: Study of the scale, nature and causes of adverse events and methods to identify them.PhD thesis. University of York; 2009.
• [33]Olsen S: Detection of adverse events in surgery by record review.PhD thesis. University of London; 2006.
• [34]Adverse events in health care - overview of adverse events and costs. Marker based record review during January - June 2013 (in Swedish). Stockholm: Sveriges Kommuner och Landsting; 2013.
• [35]Schildmeijer K, Unbeck M, Muren O, Perk J, Pukk Harenstam K, Nilsson L: Retrospective record review in proactive patient safety work - identification of no-harm incidents. BMC Health Serv Res 2013, 13:282. BioMed Central Full Text