1. Trigger Tools 4 th February 2009 Presenter: Liz Baines

2. Trigger Tools Patient Safety – The Facts Main Causes of Death: 1.Cardiovascular Disease 2.Cancer 3. Respiratory Disease 4.Adverse Events

3. Trigger Tools What is an Adverse Event? “An unintended injury or complication caused by medical management rather than the disease process. The injury is sufficiently serious to lead to prolongation of hospitalisation or temporary of permanent impairment or disability in the patient” Harvard Medical Practice Study 1990

4. Trigger Tools A Safety Culture in Healthcare People do not intend to cause harm Incidents are rarely due to single errors and are often the end product of multiple factors Analyses of incidents : less focus on the individual and more on the organisation What does this tell us about ‘our’ system Safety is everyone’s responsibility

5. Trigger Tools Errors and Harm Not all errors result in harm Not all harm is as the result of errors

6. Trigger Tools Retrospective Notes Review Prospective Observational Study

7. Trigger Tools I mpact of adverse events Direct costs Estimated cost of preventable adverse events in the USA $10.1 billion dollars (Leape et al 1993) Study in Utah and Colorado estimated the cost of adverse events to be $159,245,000. On average preventable drug events resulted in an additional 4.6 days in length of stay In England healthcare associated infections are estimated to cost over £1 billion pounds a year

8. Trigger Tools Indirect costs Increased pain and discomfort Lost earnings Impact on work & social lives Psychological trauma Disability Death Impact on carers and families At any one time 1.4 million people worldwide are suffering from infections acquired in hospital

9. Trigger Tools Impact on Healthcare workers Profound consequences Shame Guilt Litigation & complaints Anxiety Loss of confidence Impact on families & co-workers

10. Trigger Tools Why Trigger Tools? Conventional approaches to quantifying adverse events: –Voluntary Incident Reporting –Record Reviews –Observational databases 2000 The IHI Trigger Tool for Measuring Adverse Drug Events (ADE) This was based on the principle of Triggers

11. Trigger Tools Background 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

12. Trigger Tools Global Trigger Tool IHI Global Trigger Tool (GTT) goes beyond medications Focus is on adverse events related to delivery of care (acts of commission) Rather than issues related to substandard care (omissions) Omissions often leads to judgment and individual blame rather than focus on system solutions.

13. Trigger Tools

14. What does the tool tell you? Adverse Event Rate per 1000 patient days 40 per 1000 pt days = 4 per 100 pt days 1 per 25 days In a 25 bed ward = That is 1 patients harmed every day 25 per 1000 bed days = 2.5 per 100 pt days In a 25 bed ward = 2.5 incidents in 4 days That is a patient is harmed every other day

15. Trigger Tools What else can it tell us? 1000 Lives Campaign Reporting Summary Spreadsheet for the Trigger Tool

16. Trigger Tools Most frequent: G1 Lack of Early Warning score or score requiring response G4 Readmission within 30 days G7 Complication of procedure or treatment G8 Transfer to higher level of care L4 Rising urea or creatinine

17. Trigger Tools Most frequent: G7 Complication of procedure or treatment G4 Readmission within 30 days G2 Patient Fall L12 Wound Infection

18. Trigger Tools G General care S Surgical care I Intensive care M Medication L Lab tests

19. Trigger Tools E Contributed to or resulted in temporary harm to the patient & required intervention F Contributed to or resulted in temporary harm to the patient & required initial or prolonged hospitalisation G Contributed to or resulted in permanent patient harm H Required intervention to sustain life I Contributed to the patients death

20. Trigger Tools Case Note Reviews – Examples of Learning The amount of missing information in records: Prescription sheets Nursing records TPR charts

21. Trigger Tools Case Note Reviews – Examples of Learning Standard of documentation: Patient not documented as discharged Illegible hand writing Events not documented

22. Trigger Tools Trigger Tools - Summary Powerful Tool for identifying events/harm to patients Time consuming Form is not intuitive BUT has been adapted Important to keep a record of the events The Global Tool is designed for adults Other tools available e.g. Adverse Drug Events, ITU, Neonatal ICU, Outpatients, Peri-operative, Mental health

23. Trigger Tools Next Steps? Any Questions?