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10 IHI Innovations to Improve Health and Health Care
This curated publication highlights 10 ideas that have emerged from IHI's systematic 90-day innovation approach, including reflections on the Triple Aim, the concept of a health care Campaign, the Breakthrough Series Collaborative model, and other frameworks and fresh thinking that have been replicated around the world.
Development of a Trigger Tool to Identify Adverse Events and Harm in Emergency Medical Services
This article describes the development and implementation of the Emergency Medical Services Trigger Tool (EMSTT), a sampling strategy similar to the Global Trigger Tool with EMS-specific triggers, to identify and measure adverse events and harm over time in the Emergency Medical Services setting.
Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool
This study's objective was to develop and test the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool, which measures hospital-wide rates of adverse events (AEs) and preventable AEs. The study found that the GAPPS tool reliably identifies AEs among pediatric inpatients and can be used to guide and monitor quality and safety improvement efforts.
IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events
The IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse event incidence over time in skilled nursing facilities (SNFs).
National Coordinating Council (NCC) for Medication Error Reporting and Prevention (MERP)
The National Coordinating Council (NCC) is an independent body of 27 national organizations whose aim is to maximize the safe use of medications and increase awareness of medication errors through open communication, increased reporting, and promotion of medication error prevention strategies.
Signal and Noise: Applying a Laboratory Trigger Tool to Identify Adverse Drug Events among Primary Care Patients
This study tests the use of six abnormal laboratory triggers for detecting adverse drug events among adults in outpatient care.
Deciphering Harm Measurement
This article looks at several current approaches to measuring harm.
Passport Exclusive: Improvement Skills to Empower Front-Line Nurses II
This recording discusses Managing Patient Care Risk: Beyond the Checklist. How does the front-line nurse engage her team, foster communication, and improve teamwork — the three requirements for effective use of a checklist?
Passport Exclusive: Improvement Skills to Empower Front Line Nurses I
This recording discusses Developing a Sensitivity to Risk, including many tools that can help uncover and reduce risk and patient harm.
Saving lives by studying deaths: Using standardized mortality reviews to improve inpatient safety
Substantial variation existed in hospital standardized mortality ratios (HSMRs) across hospitals in the Kaiser Permanente system. In 2008, multidisciplinary teams at KP used the IHI Global Trigger Tool, along with other tools, to investigate hospital-level mortality in order to identify patterns of potential harm and focus improvement efforts.
WIHI: The Power to Detect and Improve: Revisiting the IHI Global Trigger Tool and Adverse Events
April 14, 2011 | The authors discuss a new study in Health Affairs that finds that the IHI Global Trigger Tool identified at least ten times more confirmed, serious events than other methods.
WIHI: The Power to Detect and Reduce Harm: IHI’s Global Trigger Tool and Adverse Events in the US
October 21, 2010 | This WIHI provides a window into research findings from a series of reports from the Office of Inspector General and their significance for patient safety, harm detection, improvement work, and policy reform going forward. The IHI Global Trigger Tool for identifying adverse events is also a focus of the discussion.
Global Trigger Tool shows that adverse events in hospitals may be ten times greater than previously measured
This study finds that the IHI Global Trigger Tool identifies at least ten times more confirmed, serious events than voluntary reporting and Patient Safety Indicators.
Temporal trends in rates of patient harm resulting from medical care
A retrospective study of a stratified random sample of 10 hospitals in North Carolina.
Introduction to Trigger Tools for Identifying Adverse Events
The use of triggers, or clues, to identify adverse events is an effective method for measuring the overall level of harm from medical care in a health care organization.
Pediatric ADE Patient Record Review Sheet [Included in Trigger Tool for Measuring Adverse Drug Events]
A one-page form that can be used to register information obtained from individual pediatric patient records during a review for adverse drug events (ADEs), included in the Trigger Tool for Measuring Adverse Drug Events.
IHI Trigger Tool for Measuring Adverse Drug Events
A method for using "triggers," or clues, in patient records to identify ADEs that may not have been reported through traditional mechanisms).
Pediatric Trigger Toolkit: Measuring Adverse Drug Events in the Children’s Hospital
This tool provides a powerful yet simple method to detect medication-related harm in pediatric inpatients.
Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer
Studies using physician implicit review have suggested that the number of deaths due to medical errors in US hospitals is extremely high. However, some have questioned the validity of these estimates.
The reliability of medical record review for estimating adverse event rates
The data used by the U.S. Institute of Medicine to estimate deaths from medical errors come from a study that relied on nurse and physician reviews of medical records to detect the errors.
IHI Global Trigger Tool for Measuring Adverse Events (Second Edition)
This white paper provides information on the development and methodology of the IHI Global Trigger Tool, enabling the ability to accurately identify adverse events and measure the rate of adverse events over time.
Adverse drug event trigger tool: A practical methodology for measuring medication related harm
This article describes how to use of the "trigger tool", which has been proven to increase the rate of adverse drug event detection approximately 50-fold over traditional reporting methodologies.
Pursuing Perfection: Report from McLeod on Improving Medication Safety
McLeod Regional Medical Center, a member of IHI's Pursuing Perfection program, improves their rate of medication errors by making numerous changes in their care methods beginning with a top-down change in culture.
Improvement Tip: Focus on Harm, Not Errors
While alarm continues to mount over the high number of unintended medical errors that occur in health care institutions, IHI is working with patient safety leaders to shift the focus away from counting errors. What really matters is the harm that patients suffer — some of it due to errors, but most of it resulting from flawed systems within which highly skilled providers operate.
IHI Perinatal Trigger Tool
The Perinatal Trigger Tool provides instructions for conducting a retrospective review of patient records using triggers to identify possible adverse events causing any physical harm to the infant or mother.