IHI Surgical Trigger Tool for Measuring Peri-operative Adverse Events

Institute for Healthcare Improvement
Cambridge, Massachusetts, USA

 

The use of “triggers,” or clues, to identify peri-operative adverse events (POAEs) is an effective method for measuring the overall level of harm from medical care in a health care organization. The Surgical Trigger Tool includes adverse drug events, but goes beyond medications to include any noxious or unintended event occurring in association with medical care to surgical inpatients.

 
The Surgical Trigger Tool for Measuring Peri-operative Adverse Events provides instructions for conducting a retrospective review of patient records using triggers to identify possible POAEs. This tool includes a list of known POAE triggers and instructions for measuring the number and degree of harmful events. The tool provides instructions and forms for collecting the data you need to measure the number of POAEs per 1,000 patient days and the percentage of admissions with an POAE.
 
For more general information on Trigger Tools and how to select the appropriate one, see the Introduction to Trigger Tools page.
 
Background
 
The Surgical Trigger Tool builds upon the work of the Trigger Tool for Measuring Adverse Drug Events, developed by IHI and Premier in 2000.
 
The Surgical Trigger Tool includes adverse drug events, but also goes beyond medications to include any noxious or unintended event occurring in association with medical care to surgical inpatients.
 
The World Health Organization definition of “adverse events” includes events caused by errors. Some errors are harmless, some cause injury, and some are “near misses” (that is, they do not cause injury to the patient, either by chance or because they are intercepted before being administered or provided to the patient).
 
The definition used for “harm” in the Surgical Trigger Tool is: An adverse event is an injury or harm related to (or from) the delivery of care.
 
This tool provides an easy-to-use method for accurately identifying AEs (harm) and measuring the rate of AEs over time to identify areas for improvement within the organization. Tracking AEs over time is a useful way to tell if changes being made are improving the safety of the care processes.
 
Directions
The Surgical Trigger Tool contains:
  • Background: Measuring Harm vs. Error
  • Rules and Methods for Use of the Surgical Trigger Tool
  • Surgical Trigger Tool Worksheet
  • Surgical Trigger Tool Review Summary Sheet
  • List of Global Triggers for Peri-operative Adverse Events and Explanations

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