IHI Trigger Tool for Measuring Adverse Events in the Neonatal Intensive Care Unit

Child Health Corporation of America and the Vermont Oxford Network, in collaboration with the 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 in a health care organization. The Trigger Tool for Measuring Adverse Events in the Neonatal Intensive Care Unit (NICU) provides instructions for conducting a retrospective review of patient records using triggers to identify possible AEs in the NICU. 

This tool includes a list of potential AE triggers and instructions for collecting the data you need to measure either the rate of adverse events (the total number of AEs per 100 admissions) or the percentage of admissions with an AE in your NICU. A full test of these triggers was conducted in order to construct a valid NICU Trigger Tool. The details of this study can be found in the following article:
For more general information on Trigger Tools and how to select the appropriate one, see the Introduction to Trigger Tools page.
The Institute for Healthcare Improvement (IHI) formed the Idealized Design of the Medication System (IDMS) Group in May 2000, which developed the first IHI Trigger Tool system. Since that time, IHI has expanded its Trigger Tools to include non-medication events, and other groups have developed population-specific Trigger Tools, such as a Pediatric Trigger Tool to detect adverse drug events in pediatric inpatients developed in 2001-2003 by the Child Health Accountability Initiative (CHAI) of Child Health Corporation of America (CHCA). CHCA and the Vermont Oxford Network (VON) have identified the need for a NICU-specific Trigger Tool based on the following factors:
  • IHI Trigger Tool testing in adults has found a very high level of harm in ICU and surgical patients.


  • The CHAI Pediatric Trigger Tool may not be ideal for use in the NICU population:
      • Although the NICU population seemed prone to a high number of adverse drug events (ADEs) due to their fragile medical condition and their increased risk for weight-based dosing errors, the CHAI Pediatric Trigger Tool identified a similar rate of ADEs in the neonatal population when compared to the general pediatric population. This suggested that the CHAI Pediatric Trigger Tool was not sensitive enough in the high-risk NICU population.
      • The triggers which were associated with ADEs in the neonatal population were quite different from those most commonly associated with ADEs in other pediatric patients.
      • The tool identified only drug-related adverse events, and thus did not detect adverse events related to procedures, or non-medication based therapies.
This tool provides an easy to use method for accurately identifying adverse events (harm) and measuring the rate of AEs over time. Tracking AEs over time is a useful way to determine if changes being made are improving the safety of the care processes at your institution. Many hospitals have used this tool to identify AEs, to measure the level of harm from each AE, and to identify areas for improvement in their organizations.
This NICU Trigger Tool contains:
  • Background
  • Definitions
  • Sampling and Methods for Conducting Trigger Chart Review
  • List of AE Triggers
  • FAQs about the Trigger Reviews
  • Data Collection Form: Individual Patient NICU Triggers Data Collection Form
  • Data Collection Form: NICU AE Monthly Summary Sheet



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