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

2. Welcome

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

4. 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

5. 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

6. 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

7. 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

8. Outcome Measure

9. 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

10. A Plea – Timely Reporting

11. What is the data telling us?
Lisa Williams
Data Analyst

12. 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.

13. Frequently occurring triggers
Top 4 G1 -

14. All Wales Events

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

16. What the data is telling us?

17. Demonstration of GTT Analysis Tool

18. Any Questions?

19. 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?