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Introduction to Trigger Tools for Identifying Adverse Events

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 in a health care organization. Traditional efforts to detect AEs have focused on voluntary reporting and tracking of errors. However, public health researchers have established that only 10 to 20 percent of errors are ever reported and, of those, 90 to 95 percent cause no harm to patients. Hospitals need a more effective way to identify events that do cause harm to patients, in order to select and test changes to reduce harm.

There are various Trigger Tools available on IHI.org, including:

These Trigger Tools provide an easy-to-use method for accurately identifying AEs (harm) and measuring the rate of AEs over time. Tracking AEs over time is a useful way to tell if changes being made are improving the safety of the care processes.

Choosing a Tool

There are two approaches to using the harm measures from the Trigger Tools:

To monitor an overall level of harm as a "dashboard" item
To track harm in a specific topic or area

The IHI Global Trigger Tool is designed specifically for the first approach. This is the tool to use for an organization-wide measure that can be reported to leadership. It is designed for use with the records of adult inpatients in acute care. Translated versions of the IHI Global Trigger Tool are also available (Danish, German, Swedish, and UK translations).

Improvement efforts to reduce harm require focused efforts in specific topics and areas. It is helpful to track harm measures related to the area of focus. This can be accomplished in two ways: either using a Trigger Tool specific to that area or using one module from the IHI Global Trigger Tool.

For example, if focusing on harm from medications (or adverse drug events, ADEs), use the Trigger Tool for Measuring Adverse Drug Events. This tool can be used to collect data on that type of harm only and is helpful when working on improvements to medication systems. Another option would be to use only the Medication Module from the IHI Global Trigger Tool (which is based on the ADE Trigger Tool). In both cases, data on medication harm can be collected from the same medical records that are used for the IHI Global Trigger Tool harm measure (i.e., there is no need to obtain a second set of records). The only reason to obtain additional records would be if you are focusing on a specific population for targeted improvement (e.g., the pulmonary nursing unit), in which case records obtained should be selected from that population only.

Trigger Tools for Measuring Adverse Events are also available for the Mental Health and Skilled Nursing Facility settings. Location or service specific tools, such as the Surgical Trigger Tool, are designed for use with records from that population only (e.g., surgical inpatients). The Intensive Care Unit Adverse Event Trigger Tool is designed to identify harmful events in the ICU and uses records of patients who have been in the ICU for at least two days.

Harm can also occur outside the hospital. Sometimes this is detected on the IHI Global, ADE, or Surgical Trigger Tools if it results in admission to the hospital. Since not all adverse events result in hospital admission, there is also an Outpatient Adverse Event Trigger Tool to track harm from medical care across the continuum. This tool uses outpatient records and monitors over a longer period of time.

The IHI Global, ADE, and Surgical Trigger Tools were designed for use with the adult population. However, adverse events also occur in pediatric populations and due to unique differences in care and response to care, the triggers need to be a bit different. The Trigger Tool for Measuring Adverse Events in the Neonatal Intensive Care Unit, developed by Child Health Corporation of America and the Vermont Oxford Network in collaboration with IHI, builds on the IHI Trigger Tools and offers an option for that specific population.

With all Trigger Tools, data should always be tracked over time and categorized for review, such as in a histogram. This may identify further focus areas for work. Intensive review using a subset of triggers can be very helpful, such as anticoagulant-related harm in medications, and may be used for very focused improvement efforts.

Related Information

Training Record Set for IHI Global Trigger Tool, to be used when training new reviewers how to use the tool.
Resar RK, Rozich JD, Classen D. Methodology and rationale for the measurement of harm with trigger tools. Quality and Safety in Health Care. 2003;12 Suppl 2:39-45.
Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: A practical methodology for measuring medication related harm. Quality and Safety in Health Care. 2003 Jun;12(3):194-200.
Resar RK, Rozich JD, Simmonds T, Haraden CR. A trigger tool to identify adverse events in the intensive care unit. Joint Commission Journal on Quality and Patient Safety. 2006 Oct;32(10):585-590.
Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics. 2006 Oct;118(4):1332-1340.
Griffin FA, Classen DC. Detection of adverse events in surgical patients using the Trigger Tool approach. Quality and Safety in Health Care. 2008 Aug;17(4):253-258.
Classen DC, Lloyd RC, Provost L, Griffin FA, Resar R. Development and evaluation of the Institute for Healthcare Improvement Global Trigger Tool. Journal of Patient Safety. 2008 Sep;4(3):169-177.
Adler L, Denham CR, McKeever M, Purunton R, Guilloteau F, Moorhead D, Resar R. Global Trigger Tool: Implementation basics. Journal of Patient Safety. 2008 Dec;4(4):245-249.

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