Hospitals can’t adequately address patient safety unless they understand how much harm their patients are experiencing. IHI developed the Global Trigger Tool to help hospitals more accurately detect adverse events. In the following interview, IHI faculty Fran Griffin provides background on the use and development of the Global Trigger Tool and explains its uniquely patient-centered methodology.
What is the IHI Global Trigger Tool?
The Global Trigger Tool was designed to make record review easier and faster to identify and measure adverse events or harm that patients experience in hospitals. The idea was to look in a patient’s record from a hospital stay and identify unintended things that may have happened during the stay. By using a trigger methodology, we’re able to review the records faster than if someone were to sit down and review the entire record. It allows us to get quantifiable information so that there can be measurement. By using the Global Trigger Tool, a hospital can assess the amount of harm their patients are experiencing. They can then use it to monitor their progress over time to see if their efforts are leading to improvement.
How would you define a trigger?
A trigger is something in the record that is a clue that perhaps something unintended may have happened. Many unintended consequences of medical care are sometimes viewed as complications, so they’re not reported through other systems. For example, a laboratory value might be an indication that a patient received too much of a medication or that the medication — even if it was appropriately dosed — caused an unintended consequence.
It would take a long time to sit and review the entire record from the start of a hospital stay to finish, especially if the patient had a long stay. Using the trigger methodology takes under 20 minutes — and the average is about 10 — so a nurse, pharmacist, respiratory therapist, or other clinical staff can review a record to see if are there any clues that maybe something happened that we didn’t intend. When they find that clue, they look a little deeper at that section of the record to determine whether something happened.
If we see an elevated laboratory result for a test that looks at blood clotting, for example, then we check on whether that person is receiving a blood thinner and, if so, whether documentation indicates some bleeding or bruising. We would call that harm because that was not the intent of administering the medication.
One of the things that makes the Global Trigger Tool unique is that it looks at harm from the patient perspective. Would you comment on why that’s the case?
Harm has often been viewed through the lens of asking if it was preventable or not. That’s important, of course, but things also happen to patients that are not clearly preventable but unpleasant and unintended. We try to add that perspective. In fact, in the IHI Global Trigger Tool for Measuring Adverse Events (Second Edition) white paper, we encourage reviewers to ask, “If I were the patient, would I want this to happen to me?” If the answer is no, then maybe it is something we should think about as harm, even if we don’t know yet how to always prevent it.
Why was the Global Trigger Tool developed?
The Global Trigger Tool was developed because we have not had good systems for measuring harmful events in hospitalized patients. There are a variety of methods commonly used to identify these — such as voluntary reporting, error systems, or using coding from the medical record for billing — but they all tend to woefully underestimate what’s going on.
The publication of the Institute of Medicine To Err Is Human report in 1999 was the first major spotlight on this issue. It estimated that 98,000 people or more a year were dying from medical errors in hospitals. This compelled us to consider how we might measure harm in a way that gives us valuable information without placing a huge burden on staff. The idea of medication triggers came from the work of Dr. David Classen and others at LDS Hospital.
Our first trigger tool was based on medication events. That work expanded to trigger tools for surgical, intensive, and perinatal care. Then, as more and more hospitals started working on patient safety, we recognized that there was a need to have a global measure across the hospital that captured multiple types of events. Thus, we pulled together the triggers from the individual tools to create something that could be used to assess at a hospital-wide level and we named it the Global Trigger Tool.
What makes the Global Trigger Tool an important patient safety tool?
The consistent feedback we’ve heard from people who have used the Global Trigger Tool is that it provides information about harm and adverse events in their hospital that is not coming through any other existing system. [Conventional] reporting systems don’t capture it. Complication reports don’t always capture it. It’s not captured in morbidity and mortality review. The tool results in a metric, something quantifiable that can be put into a run chart or control chart and tracked over time. It can be used to share information with a board, for example, about how a hospital is doing and to see if investments in patient safety work are making an impact. It’s also based on clinical review. Some of the automated tools like patient safety indicators use financial data or coding for billing that can miss adverse events or harm or lead to false positives.
An interesting experience occurred when an objective third party of compared the Global Trigger Tool to other commonly used methods to measure adverse events. About 10 years ago, the US Department of Health & Human Services Office of Inspector General was charged by Congress to measure harm experienced by Medicare patients in hospitals. They did a pilot study looking at two counties to learn which method [of detecting harm] was going to give them the best data. They looked at voluntary reporting, hospital-acquired conditions, patient complaints, patient safety indicators, and the Global Trigger Tool. At the end of that pilot study, the review team concluded that the Global Trigger Tool methodology gave them more information than any of the other four combined. They then conducted a national study using the Global Trigger Tool to report back to Congress on inpatient harm for Medicare beneficiaries in the United States.
How has the Global Trigger Tool evolved?
The Global Trigger Tool was first developed for use in US hospitals. The language was based on US terminology (including medication names) and typical laboratory result ranges. Over the years, organizations outside of the US have translated and adapted it. It’s been adapted multiple times in England, Scotland, Wales, and Australia. There are also versions in Sweden, Norway, Germany, and Denmark. I believe there’s a Spanish version now as well as one in Japan.
We’ve also encouraged organizations to modify the triggers or add their own triggers based on local conditions. I remember once receiving an email asking how to address a specific trigger —a medication used for treating allergic reactions — because that hospital didn’t have that medication in their formulary. Since they had a different medication for treating allergic reactions, I suggested that they modify this trigger to what they use to make it locally applicable.
Would you share one of your favorite stories about the Global Trigger Tool?
When we were developing some of the triggers, we needed people who had done other types of trigger reviews to test the methods for us. One hospital tested the surgical triggers by reviewing records for surgical patients who had already been reviewed by their local Morbidity and Mortality (M&M) conference.
When we had a conference call with them to review their testing, I can still remember the person from that hospital saying, “We had 20 records of patients who had all been through M&M review and deemed to have no quality issues. When we reviewed them again using the triggers, we found an adverse event rate of 30 percent!” They told us that even if IHI ended up deciding not to use the surgical triggers going forward, they planned to keep the methodology. They decided to replace their M&M review with the trigger methodology because it gave them information about quality issues that had not been identified previously.
Editor’s note: This interview has been edited for length and clarity.
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You may also be interested in:
The IHI Patient Safety Congress (May 15–17, 2019, in Houston, TX)
IHI white paper - IHI Global Trigger Tool for Measuring Adverse Events (Second Edition)
Health Affairs - ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured