All | IHI - Institute for Healthcare Improvement

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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.

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.

IHI Global Trigger Tool Training Resources

A suggested plan and resources to help train reviewers on the IHI Global Trigger Tool methodology.

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).

IHI Global Trigger Tool for Measuring Adverse Events

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.

Training Record Set for IHI Global Trigger Tool

Use this Training Record Set to train new reviewers how to use the IHI Global Trigger Tool for Measuring Adverse Events.

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.

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.

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.

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.

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 Outpatient Adverse Event Trigger Tool

This tool is used to identify outpatient-related adverse events using specifically defined "triggers" (or clues).

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.

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).

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.

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.

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.

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?

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.

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.

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.

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.

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.