1. The CAPHC Paediatric Trigger Tool
Implementation for Patient Safety and Quality Improvement
Webinar Pilot – May 29, 2009

2. Purpose of the WEBINAR
To launch the CAPHC Paediatric Trigger Tool (CPTT) for use in quality improvement activities directed towards improved patient safety for infants, children and youth
Overall goal of improved safety in patient care is to reduce harm to patients
It is important to distinguish between errors and actual harm
An AE is defined as an unintended injury or complication that results in disability and is caused by healthcare management, not underlying disease
An error is defined as a failure in processes of care and is not always associated with harm to the patient
Because many healthcare errors are not linked to harm concentrating improvement efforts on harm experienced by patients (i.e. by using a trigger tool) targets the system and engages healthcare professionals to pursue complete review of factors that led to an adverse event with a focus on improving patient outcomes
The CPTT was specifically designed as an aid in the detection, quantification and tracking of adverse events and harm in hospitalized children

3. Assumptions Webinar participants:
Agree that adverse events (AEs) and the associated harm and disability are an issue for hospitalized paediatric patients
Are considering use of the CPTT as a component of an overall patient safety strategy for their organization

4. Webinar Outline Development of the CPTT
Uses of the CPTT for Improving Patient Safety
System Capabilities of the CPTT
Resource Requirements at Health Centres
Getting started using the CPTT

5. An electronic tool intended to assist healthcare providers to:
What is the CPTT?
An electronic tool intended to assist healthcare providers to:
Identify adverse events (AEs) and associated harm in hospitalized paediatric patients (DETECT)
Develop a database for measurement of patient safety outcomes
Create metrics to estimate the incidence of AEs in an organization (QUANTIFY)
Monitor the incidence of AEs over time (TRACK)
Measure the effectiveness of hospital safety programs
Target key areas for improvement
CPTT is not in itself an improvement methodology. The CPTT enables data acquisition and analysis of areas where harm is occurring and where interventions are needed to correct problems.

6. Development of the CPTT
Trigger tool methodology:
What is a trigger ?
How do triggers work to identify adverse events ?
What triggers were chosen for the CPTT and why ?
Trigger – a sentinel word, a clue, a specific event that is linked to the possible occurrence of an adverse event
The presence of a “trigger” in the patient chart identifies the need to initiate a more detailed audit of the chart for AE’s
Auditing of a trigger positive chart determines whether an injury (adverse event) has occurred
Regular surveillance of charts for triggers and adverse events enables development of processes to change systems to reduce injury in patient care
The CPTT triggers were chosen through review of 5 existing trigger tools, none of which were pediatric-specific
Through a process of feasibility testing and validation, the final 35-trigger CPTT was developed
The 35 CPTT triggers are arranged in 6 Modules – Care, ICU, Lab, Medication, Surgical and Other
Examples of triggers include: transfusion or use of blood products, infection, unplanned return to surgery, etc.
The CPTT supports evaluation of “causation” of adverse events – i.e. whether caused by health care management or not
The CPTT supports evaluation of the degree of harm associated with the AE using the NCC-MERP Index

7. Development of the CPTT
What is the capacity of the CPTT for detecting AEs in hospitalized paediatric patients ?
Validity and reliability
Sensitivity
Specificity
The validity of the CPTT is based on the sensitivity (% of trigger positive charts that have an adverse event) and the specificity (% of trigger-negative charts that did not have an adverse event)
The positive predictor value of each trigger was measured and used to reduce the number of triggers in the CPTT to 35
The sensitivity of the CPTT is 0.88 (95% CI 0.79 – 0.94)
The specificity of the CPTT is 0.44 (95% CI 0.39 – 0.48)
Interesting to note – in the review of 600 charts from 6 pediatric hospitals for the validation study, 89 patients had AEs, and 22.5% had more than one AE. Of the 89 patients with AEs, 60% had at least one preventable AE.

8. Uses of the CPTT
To create a systematic process for collection and storage of patient safety data
To identify specific areas for improvement and those that are in most need of improvement
To measure the effectiveness of initiatives taken to improve patient safety
The focus and purpose of the CPTT is on detection, quantification and tracking of AEs, allowing for accurate assessment of harm and identification of the contributing factors

9. Using the CPTT to support Patient Safety
Random routine chart audit conducted on a regular schedule
Review of discrete populations or healthcare processes – e.g. NICU, Pediatric Cardiac Surgery, etc
Special Situations – n of 1 chart reviews, RCA, etc.
Concurrent review in high risk areas
Establish a baseline and ongoing monitoring of AE rates
Evaluate compliance with incident reporting
An as a component of the M& M review process

10. Capacity/Capabilities of the CPTT
Data entry and on site storage
Privacy and security
Data analysis and reporting
Benchmarking
Education

11. Resource Requirements
Chart selection
The review process
The two-stage process
Who should conduct the reviews
What training/qualifications are required to do the chart reviews
Time required to conduct the chart reviews
Tips and strategies
CPTT is most often used to conduct retrospective review of charts for the presence of triggers and associated AEs
Chart selection is usually random, small samples, conducted on a regular basis to establish a baseline and standardized evaluation process
The chart review using the CPTT has been designed as two stage process
Primary reviewers audit the chart for the presence of triggers
Physician reviewers then audit trigger positive charts for the presence of adverse events, and make judgments about causation and harm
Reviewers can be trained in use of the CPTT using the educational program embedded in the tool
The primary chart review takes approximately 40 minutes per chart
Primary reviewers are generally nurses with a broad range of experience, or health record professionals
The physician review may take up to 30 minutes depending on how many triggers are identified in the primary review
When working with a consistent team of reviewers, it is helpful to determine the inter-rate reliability

12. Getting started using the CPTT
How to acquire/download the CPTT
System requirements
Embedded instructions on use of the software
Where to find help

13. Recommended Reading
Resar, R. K., Rozich, J. D., & Classen, D. (2003). Methodology and rationale for the measurement of harm with trigger tools. Qual. Saf. Health Care, 12, ii39-45.
Adler, L. et al (2008). Global Trigger Tool: Implementation Basics. J Patient Saf, 4, 245 – 249.
Griffin, F. A. & Resar, R. K. (2009). IHI Trigger Tool for Measuring Adverse Events (2nd ed.). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for healthcare Improvement. (available on