Institute for Healthcare Improvement
Cambridge, Massachusetts, USA
The use of “triggers,” or clues, to identify adverse events (AEs) is an effective method for measuring the overall level of harm from medical care experienced by patients in one or more intensive care units. The Intensive Care Unit (ICU) Adverse Event Trigger Tool includes adverse drug events, but also goes beyond medications to include any unintended event occurring in association with medical care to patients in an intensive care unit.
The ICU Adverse Event Trigger Tool provides instructions for conducting a retrospective review of patient records using triggers to identify possible AEs. This tool includes a list of known AE 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 AEs.
Background
The ICU Adverse Event Trigger Tool builds upon the work of the Trigger Tool for Measuring Adverse Drug Events, developed by IHI and Premier in 2000.
The ICU Adverse Event 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 ICU Adverse Event 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 ICU Adverse Event Trigger Tool contains:
Triggers: Validity, Selection Methodology, and Rationale
Chart Selection Process
Review Technique and Training Recommendations
Adverse Event Rules Standards
Case Study for Training
ICU Adverse Event Trigger Tool Workshee
