Difference between revisions of "Identifying Previously Undetected Harm: Piloting the Institute for Healthcare Improvement's Global Trigger Tool in the Veterans Health Administration"
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== Introduction == | == Introduction == | ||
| − | Adverse Event (AE) detection is an essential component of organizational patient safety programs, but at the moment, most organizations use resource-intensive and unreliable methods to detect these errors, such as random chart reviews or voluntary incident reporting. The Institute for Healthcare Improvement (IHI) developed a set | + | Adverse Event (AE) detection is an essential component of organizational patient safety programs, but at the moment, most organizations use resource-intensive and unreliable methods to detect these errors, such as random chart reviews or voluntary incident reporting. The Institute for Healthcare Improvement (IHI) developed a set of algorithms for different AEs and have a specific protocol for confirmatory chart review that is much less time and resource-intensive than traditional random chart review protocols. So far, this process has been found to be better at determining "true positive" adverse events than many other methods. |
| − | This study proposes to assess the effectiveness of the Institute for Healthcare Improvement’s Global Trigger Tool (GTT) in a VA facility by examining the overlap of | + | This study proposes to assess the effectiveness of the Institute for Healthcare Improvement’s Global Trigger Tool (GTT) in a VA facility by examining the overlap of AE detection between GTT and existing surveillance measures. |
== Methods == | == Methods == | ||
Revision as of 21:44, 11 November 2015
This is a review of the 2015 article "Identifying Previously Undetected Harm: Piloting the Institute for Healthcare Improvement's Global Trigger Tool in the Veterans Health Administration" by Mull et al.[1]
Introduction
Adverse Event (AE) detection is an essential component of organizational patient safety programs, but at the moment, most organizations use resource-intensive and unreliable methods to detect these errors, such as random chart reviews or voluntary incident reporting. The Institute for Healthcare Improvement (IHI) developed a set of algorithms for different AEs and have a specific protocol for confirmatory chart review that is much less time and resource-intensive than traditional random chart review protocols. So far, this process has been found to be better at determining "true positive" adverse events than many other methods.
This study proposes to assess the effectiveness of the Institute for Healthcare Improvement’s Global Trigger Tool (GTT) in a VA facility by examining the overlap of AE detection between GTT and existing surveillance measures.
Methods
Trigger examples: Possible Adverse Events: (e.g.: blood or blood product; device or medical-surgical supply, including health information technology; fall; HAI; medication or other substance; pressure ulcer; surgery or anesthesia; and venous thromboembolism)
Results
109 AEs identified using GTT methodology
88% of identified AEs were not detected by the existing surveillance measures such as VA Surgical Quality Program (VASQIP) or Patient Safety Quality Indicators (PSIs)
60% the AEs identified resulted in minor harm
Discussion
Comments
Related Articles
Electronic health record-based triggers to detect potential delays in cancer diagnosis
Electronic health record-based surveillance of diagnostic errors in primary care
References
- ↑ http://www.ncbi.nlm.nih.gov/pubmed/?term=Identifying+Previously+Undetected+Harm%3A+Piloting+the+Institute+for+Healthcare+Improvement%E2%80%99s+Global Mull HJ, Brennan CW, Folkes T, Hermos J, Chan J, Rosen AK, Simon SR.Identifying Previously Undetected Harm: Piloting the Institute for Healthcare Improvement's Global Trigger Tool in the Veterans Health Administration. Qual Manag Health Care. 2015 Jul-Sep;24(3):140-6. doi: 10.1097/QMH.0000000000000060.
