Why It Matters
The IHI Global Trigger Tool has facilitated updated estimates of patient harm, highlighting the urgent need to develop new ways - and reliably implement known ways - to improve patient safety.
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The IHI Global Trigger Tool: Changing Safety for a Decade

By Joelle Baehrend | Friday, September 15, 2017


The Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) for Measuring Adverse Events, freely available on the IHI website for more than 10 years, has provided organizations across the globe with an easy-to-use method for accurately identifying and learning from patient harm to improve safety and reduce patient suffering.

Developed by the Institute for Healthcare Improvement in 2003 as part of the Idealized Design of Medication Systems project, funded by Premier, Inc., the GTT allows organizations to quantify actual harm to patients. Because adverse events that lead to patient harm have a clear impact on clinical outcomes, such events are likely to engage both clinicians and administrators in a thorough review of the system factors that led to the adverse event, with a clear focus on improving patient outcomes. By concentrating on harmful events experienced by patients, a hospital can begin to foster a culture of safety that shifts from individual blame for errors to comprehensive system redesign that reduces patient suffering and the potential for future occurrence of such events.

Updated Estimates of Harm and Avoidable Premature Death

Use of the IHI Global Trigger Tool has facilitated new estimates of patient harm in the United States, highlighting the urgent need to develop new interventions and reliably implement known interventions to improve inpatient safety. A 2011 study published in Health Affairs by Classen and colleagues found that adverse events in US hospitals are as much as ten times more common than previous estimates, while a 2012 study published in Pediatrics by Kirkendall and colleagues found a rate of harm in the pediatric inpatient setting to be as much as three times higher than previously published rates. In a 2013 literature review by James published in the Journal of Patient Safety of four studies that used the GTT, the author estimates 400,000 deaths in the United States each year due to preventable harm.

How to Use the IHI Global Trigger Tool

The IHI Global Trigger Tool uses the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Errors as the basis for categorizing adverse events. The GTT uses a subset of the NCC MERP categories, categories E through I, because these categories describe harm.

A team reviews a sample of closed inpatient records for positive triggers as indicated in the GTT. The identification of a positive trigger is not necessarily an indication that an adverse event has taken place, but rather a prompt to check other relevant portions of the record to determine if the patient experienced harm as a result of the event. If the team finds harm, reviewers then assign a category of harm (category E through I) to each adverse event identified during record review.

Spread and Adaptations

Since its development in late 2003, use of the IHI Global Trigger Tool has spread from collaborative projects to large-scale improvement efforts. Hundreds of hospitals in multiple countries now use the GTT to monitor adverse event rates while working to improve patient safety. The tool has been adapted for use in the pediatric care setting, the NICU, dentistry, mental health, outpatient care, surgical care, skilled nursing facilities, and ambulance service; it has been translated into at least five languages (Danish, German, Swedish, Italian, and Portuguese) and has been used in the United Kingdom, Sweden, Norway, Belgium, Finland, Brazil, New Zealand, China, Korea, Australia, and Palestine. Health care providers and researchers from around the world continue to use and adapt the Global Trigger Tool methodology to guide their efforts to reduce harm and suffering, build will for change, and improve patient safety.

Joelle Baehrend, MA, is an IHI director and member of the patient safety team.

Editor’s Note: The IHI Global Trigger tool is freely available on the IHI website along with an implementation tool kit, a training record set, and several adaptations and translations. The IHI White Paper, IHI Global Trigger Tool for Measuring Adverse Events, provides additional background and guidance.

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