Faculty Profiles. IHI Global Trigger Tool for Measuring Adverse Events March 20, Roger Resar, MD Frances A.

Transcription

1 IHI Global Trigger Tool for Measuring Adverse Events March 20, 2007 Roger Resar, MD Frances A. Griffin, RRT, MPA Faculty Profiles Roger K. Resar, MD, Senior Fellow, Institute for Healthcare Improvement, practiced Pulmonary and Critical Care Medicine for 30 years prior to joining the Institute for Healthcare Improvement. He has contributed to bundle theory, reliability in health care process design, flow, and safety. He and other colleagues at IHI have authored multiple papers on using the IHI Global Trigger Tool to detect adverse events. Frances A. Griffin, RRT, MPA, is a Director at the Institute for Healthcare Improvement. She has worked with IHI since 1999, initially as faculty for patient safety. A full-time IHI staff member since 2002, Ms. Griffin has supported the development of content in patient safety and reliability, directed Collaborative projects, and served as faculty for the 100,000 Lives and 5 Million Lives Campaigns. She is a codeveloper of the IHI Global Trigger Tool. Ms. Griffin is a Registered Respiratory Therapist and holds a Master s Degree in Public Administration. She has 20 years of hospital experience, including administrative oversight for quality, case management, and other related departments.

2 Background Why Use Trigger Tools? Traditional reporting of errors, incidents, or events does not reliably occur in the best of cultures in health care. Voluntary methods underestimate events and frequently concentrate on what is interpreted as being preventable. Trigger Tool easily identifies events without complex technology. Trigger Tool can be integrated into a good sampling methodology. Resar RK, Rozich JD, Classen D. Methodology and rationale for the measurement of harm with trigger tools. Quality and Safety in Healthcare. 2003;12 Suppl 2:39-45.

3 Question to Ponder What percent of medical errors actually lead to harm? 3.7% of patients experienced adverse events; 58% due to error (Harvard Medical Practice Study, 1991) 2.99% of reported medication errors (41,296) led to harm (Med Marx 2000 Report; NCC MERP data) 5% of reported medication errors (>11,000) in perioperative settings led to harm US Pharmacopiea 3/5/07 Terminology Adverse Event vs. Error Error definition bears upon concept of preventability, and is therefore process focused. Adverse event describes harm to the patient, and is thus outcome focused. Relationship between errors and adverse events: Adverse Events Mortality Errors

4 Definition of Harm World Health Organization (WHO) Collaborating Centers for International Drug Monitoring defines an adverse drug event as follows: Noxious and unintended and occurs at doses used in man for prophylaxis, diagnosis, therapy, or modification of physiologic functions. The IHI Global Trigger Tool includes these PLUS any noxious or unintended event occurring in association with medical care. HARM = Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death. IHI Global Trigger Tool Measures harm, not error Measures events associated with commission rather than omission Does not decide between preventable and non-preventable

5 Adverse Events New (Harm) vs. Old (Errors) Concentrates less on people, more on systems Looks at all unintended results Makes measurement easier Errors are the focus of discussion and solutions Tends to focus only on those results felt to be related to error, ignores other events Requires judgment Concentrates on harm and those errors that cause harm Human found responsible for most of the errors Category of Harm (from NCC MERP Index) E- Temporary harm, intervention required F- Temporary harm, initial or prolonged hospitalization G- Permanent patient harm H- Life-sustaining intervention required I- Contributing to death

6 Record Review Triggers for Medication Events Diphenhydramine Vitamin K Romazicon Anitemetics Naloxone Antidiarrheals Serum glucose <50 WBC <3,000 Platelet <50,000 Digoxin level > 2 Rising serum creatinine Oversedation / fall / lethargy / hypotension Rash Abrupt medication stop Transfer to higher level of care C. difficile positive PTT > 100 seconds INR > 6 Multi-center Trigger Adverse Drug Event (ADE) Review 2,837 patient records reviewed using Trigger Tool 86 institutions 720 ADEs found on reviews 268,796 medications doses administered ADEs/1000 doses = 2.67 Admissions with ADEs = 24.9% Rozich JD, Haraden CR, Resar RK. The adverse drug event trigger tool: A practical methodology for measuring medication-related harm. Quality and Safety in Health Care. 2003;12:

7 Multi-center ICU Trigger Tool Review 12,074 ICU admissions reviewed 62 ICUs in 54 institutions 11.3 adverse events/100 ICU days 55% of admissions suffered at least one adverse event 28% of admissions had more than 1 event 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. Oct 2006;32(10): Key Learning Adverse event rate was higher than anyone had previously measured. Methodology was relatively easy to teach and learn. Considerable resistance exists to identify harm that is not related to current (in current state). Organizations were anxious to find a new and useful tool for adverse event measurement. Improvement efforts could be tied or at least be related to findings. Improvement over time could be measured.

8 Knowledge Gained Resource-friendly methodology Easy to train reviewers with reasonable consistency Organizations accept the harm concept readily Good board level report Allows for organizational goal setting IHI Global Trigger Tool (GTT) Natural extension from topic- or location-specific Trigger Tools Uses multiple modules of triggers Gathers events from the whole hospital Establishes global harm measure for the hospital Resource-friendly and no dependency on high tech

9 IHI Global Trigger Tool (GTT) Currently used in hundreds of hospitals throughout the world Undergoing a rigorous comparison to other methodologies Incorporates identification of events throughout the hospital!!! "!! #

10 Example of a trigger: Case #1 -Transfer to higher level of care Patient underwent elective endoscopy Post procedure somnolent and hypotensive (BP 80) transferred to ICU Placed on Bi-Pap due to respiratory depression Received standard Demerol and Versed for procedure Given Romazicon; stayed in unit 12 hours Analysis Without timely intervention, patient may have been likely to experience respiratory arrest, possibly leading to death. BiPAP as non-invasive ventilation became life saving. This event would be category H.

11 Case Example # 2 A patient on chronic anticoagulation with INR of 8.2, identified during trigger review In itself, the abnormal INR is not an adverse event. The appropriate portion of the record must be reviewed to determine if an adverse event has occurred. Large retroperitoneal bleed has been diagnosed. The event has caused a prolongation of the hospitalization and is thus classified as a category F. IHI Global Trigger Tool Modules Cares Critical Care Medication Surgery Labor & Delivery Emergency Department

12 C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 C13 C14 C15 Cares Module Triggers Transfusion or use of blood products Any Code or arrest Dialysis Positive blood culture X-ray or Doppler studies for emboli Abrupt drop of greater than 25% in Hg or Hematocrit Patient fall Decubiti Readmission within 30 days Restraint use Infection of any kind In-hospital stroke Transfer to higher level of care Any procedure complication Other IHI GTT Validation Training records pulled from two organizations and reviewed by two physicians as the comparison standard Mid-level record reviewers (non-physicians) trained using the training records Three in-depth reviews of 800 records from three organizations IHI GTT compared to all other event measurements for the same time period

13 What would this mean to a hospital with 10,000 admissions? 5,000 adverse events would occur in these 10,000 admissions. 50 patients would die unnecessarily. 350 patients would require life-saving interventions to avoid death from an event patients would be admitted or have hospital stay prolonged due to an adverse event patients would have temporary harm from an event. Examples of E Bladder perforation secondary to surgery Pressure ulcer Dissection of artery during procedure Post-op wound infection 4 th degree vaginal laceration Hypoglycemia Acute renal failure secondary to drugs

14 Trigger Tool Practical Use Trigger Tool establishes a baseline of adverse events for a hospital. Types of adverse events can be catalogued and prioritized. Resources can be focused on those events causing the greatest harm. Effect of interventions can be monitored when adverse event rate is measured over time. Getting Started

15 Identify & Train Review Team Select reviewers and physician advisor. Read and discuss the IHI Global Trigger Tool Guide. ools/ihiglobaltriggertoolformeasuringaes.htm Practice with the IHI Training Records. Complete a review with your own records. Reviewer Methodology Each record is reviewed in a two-step process. Each record is reviewed by two non-physician reviewers and a consensus is reached. A physician reviewer reviews only the consensus and agrees or changes the consensus decision. Records are reviewed every two weeks.

16 Steps in Review Process Set a timer for 20 minutes Review: Coding summary (look for e-codes and obvious events) Discharge summary Orders Medication administration record Laboratory results X-ray reports procedure notes Nursing / multidisciplinary notes (if time left) Key Points Follow recommended sequence for review. Look for triggers only don t read the entire record. Remember that a positive trigger is not necessarily an adverse event. Determine and assign harm based on perspective of patient: Did I suffer harm?

17 Determining Harm Minor events need to be graded and are open to subjective decisions. EXAMPLE: A little nausea treated and resolved is not an adverse event; a lot of nausea is. H events (life-saving intervention) occur when measures need to be taken to save the patient s life within a short period of time (e.g., within an hour). Most important: BE CONSISTENT. Counting Adverse Events Post-operative complications are always adverse events, even if expected (they are still unintended). An adverse event found without a trigger should be included in your data. All events are counted, even if they occurred outside of hospital. The perspective is the harm experienced by the patient, not the location. Track these separately if you wish.

18 Considerations Two reviewers will both pick up the G-,H-, and I-level harms almost 100% of the time. 75% of the time the E and F will be picked up by at least one of the two reviewers. Definitions of harm become more standard with two reviewers - reviewers need to be relatively constant. Physicians do not review the records; they review the consensus between the two mid-level reviewers. Basic Principles Review with a trained team. Select a small, random sample. Look for the presence of triggers only. Determine whether harm occurred from perspective of the patient. Assign category of harm. Tabulate data and track over time. DO NOT REPORT UNTIL YOU HAVE COLLECTED AT LEAST 12 DATA POINTS.

19 Drilling Down with the Data Modules within the Trigger Tool can be used for focused reviews. Use the Medications Module to track ADEs. This can be reported as an additional measure. Drill down when you see areas of concern to monitor for specific improvement. Example: Use those triggers related to adverse events for anticoagulants to track ADEs from these medications while working to improve. Drill-down measures will improve before the overall adverse event rate. Resources IHI Global Trigger Tool Training Records Answers to the training records Discussions