Carmen Astargo Vega is a nurse who has been working in a quality and patient safety unit in Chile for the past four years. For her master of public health thesis, she used the IHI Global Trigger Tool (GTT) to measure adverse events at a hospital in Chile. IHI Latin America Project Assistant Gabriella Cova interviewed her to learn more about how this tool is helping advance patient safety in a country where the movement is just beginning.
Was there a particular adverse event that motivated you to work in patient safety?
The event that impacted me the most involved a pregnant woman who had a procedure done that resulted in a broken artery, and she lost the baby as a result. It was terrible. During the assessment of the event, it was evident that there were medical errors that had not been reported. At the time, the event was not analyzed as an adverse event. However, the team learned from it and made improvements in reporting medical errors. This motivated me to dedicate myself to the work of documenting, reporting, and assessing adverse events.
Why did you decide to apply the GTT for your master’s thesis?
I saw an opportunity to apply the GTT to the local context. Patient safety is not very developed in Chile. Reporting of adverse events is generally done on a voluntary basis, and there is still a culture of blame that hinders health systems from learning from errors.
The hospital culture here is very hierarchical — the doctor is always right, and it is difficult to tell them they made a mistake. Medical experts can find it difficult to acknowledge an adverse event, which further strains communication with the patient and adds to the judgmental culture surrounding these events. It takes a lot of work to be able to show that each adverse event is a learning opportunity rather than one designed to blame people for their errors.
It was challenging to take on this project. As I was developing my thesis, I struggled to find advisors and an institution that would allow me to carry it out. The biggest challenge lay in the organization of medical records. But I persisted because I knew that it was a tool that could improve patient safety in Chile.
What was the adverse event reporting process like in the hospital before using the GTT?
Where I conducted my thesis, adverse events are documented and reported using written forms and clinical audits. Clinical teams registered by the quality office then analyze the reported events. However, in Chile, there are no specific guidelines on the documentation, reporting, and analysis of adverse events, so after using the GTT, we found that more than 90 percent of the events had not been reported to the institution.
Do you think your project changed the situation at the hospital?
In theory, yes, but not so much in practice. Quality improvement experts have been very supportive and optimistic about the potential of adopting the GTT, but it has been difficult to get the buy-in from the hospital leadership. Currently the institution is working on a systematic implementation of the GTT.
How will you use your thesis to promote the adoption of the GTT?
Chile needs the Ministry of Health to promote the identification and report of adverse events at a national level. I shared the results of my thesis with the head of quality at the Ministry of Health, so they can see evidence that the GTT works and can develop guidelines and protocols for quality offices to adopt and pilot the tool. Having used and tested this tool in Chile was a good first step.
You may also be interested in:
IHI white paper: IHI Global Trigger Tool for Measuring Adverse Events (Second Edition)
Introduction to Trigger Tools for Identifying Adverse Events