The Global Trigger Tool Content Session Liz Baines – GTT Specialist Lisa Williams – Data Analyst

Welcome

Programme 12.00 -12.20 Over view of GTT in Wales 12.20 -1.00 Communication and the GTT (Panel discussion) 1- 1.50 pm LUNCH 2.00 - 3.40 Feedback 3.40 – 4.00 Planning and next steps

2 Years and Counting The 1000 Lives Campaign is aiming to save 1000 lives and to avoid 50,000 episodes of harm in Welsh healthcare between 21st April 2008 and 21st April 2010 Just introduce yourself, you have 10 mins each

Measures of Harm Conventional approaches to quantifying adverse events: Voluntary Incident Reporting Record Reviews Observational databases The Global Trigger Tool was devised by the IHI This was based on the principle of Triggers

Why Trigger Tools? Trigger Tools focus on identifying harm as opposed to errors By focusing on events experienced by patients it can help shift the culture from individual blame for errors. This can facilitate system redesign

GTT Approach Provides a tool for a systematic case note review 20 cases per month Review for triggers then asses for harm Triggers are in modules Calculates rate of harm adverse event rate per 1000 patient days

Outcome Measure

What does this mean? Adverse event rate per 1000 patient days 40 per 1000 pt days = 4 per 100 In a 25 bed ward = 4 incidents in every 4 days That is 1 patient harmed in every 24 hours on every ward 20 per 1000 bed days = 2 per 100 pt days In a 25 bed ward = 2 incidents in 4 days That is a patient is harmed every other day

A Plea – Timely Reporting

What is the data telling us? Lisa Williams Data Analyst

All Wales Triggers by module * Data represent 9/12 Trusts. 2 exclusions Powys and WAST completely different methodology. And one Trust was unable to report the data.

Frequently occurring triggers Top 4 G1 -

All Wales Events

What the data is telling us? Where is most of the harm occurring?

What the data is telling us?

Demonstration of GTT Analysis Tool

Any Questions?

Questions What is the GTT telling us about the organisation? How& Where is this information being communicated? What is the process for dealing with the serious cases we identify? What are we doing to improve our systems and processes?