4 th February 2009 Trigger Tools Presenter Liz

4 th February 2009 Trigger Tools Presenter: Liz Baines Trigger Tools

Patient Safety – The Facts Main Causes of Death: 1. 2. 3. 4. Cardiovascular Disease Cancer Respiratory Disease Adverse Events Trigger Tools

What is an Adverse Event? “An unintended injury or complication caused by medical management rather than the disease process. The injury is sufficiently serious to lead to prolongation of hospitalisation or temporary of permanent impairment or disability in the patient” Harvard Medical Practice Study 1990 Trigger Tools

A Safety Culture in Healthcare • People do not intend to cause harm • Incidents are rarely due to single errors and are often the end product of multiple factors • Analyses of incidents : less focus on the individual and more on the organisation • What does this tell us about ‘our’ system • Safety is everyone’s responsibility Trigger Tools

Errors and Harm • Not all errors result in harm • Not all harm is as the result of errors Trigger Tools

Prospective Observational Study Retrospective Notes Review Trigger Tools

Impact of adverse events Direct costs • Estimated cost of preventable adverse events in the USA $10. 1 billion dollars (Leape et al 1993) • Study in Utah and Colorado estimated the cost of adverse events to be $159, 245, 000. • On average preventable drug events resulted in an additional 4. 6 days in length of stay • In England healthcare associated infections are estimated to cost over £ 1 billion pounds a year Trigger Tools

Indirect costs • • Increased pain and discomfort Lost earnings Impact on work & social lives Psychological trauma Disability Death Impact on carers and families At any one time 1. 4 million people worldwide are suffering from infections acquired in hospital Trigger Tools

Impact on Healthcare workers • • Profound consequences Shame Guilt Litigation & complaints Anxiety Loss of confidence Impact on families & co-workers Trigger Tools

Why Trigger Tools? • Conventional approaches to quantifying adverse events: – Voluntary Incident Reporting – Record Reviews – Observational databases • 2000 The IHI Trigger Tool for Measuring Adverse Drug Events (ADE) • This was based on the principle of Triggers Trigger Tools

Background • Trigger Tools focus on identifying harm as opposed to errors • By focusing on events experienced by patients it can help shift the culture from individual blame for errors. • This can facilitate system redesign Trigger Tools

Global Trigger Tool • IHI Global Trigger Tool (GTT) goes beyond medications • Focus is on adverse events related to delivery of care (acts of commission) • Rather than issues related to substandard care (omissions) • Omissions often leads to judgment and individual blame rather than focus on system solutions. Trigger Tools

Trigger Tools

What does the tool tell you? • Adverse Event Rate per 1000 patient days 40 per 1000 pt days = 4 per 100 pt days 1 per 25 days In a 25 bed ward = That is 1 patients harmed every day • 25 per 1000 bed days = 2. 5 per 100 pt days In a 25 bed ward = 2. 5 incidents in 4 days That is a patient is harmed every other day Trigger Tools

What else can it tell us? • 1000 Lives Campaign Reporting Summary Spreadsheet for the Trigger Tools

Most frequent: G 1 Lack of Early Warning score or score requiring response G 4 Readmission within 30 days G 7 Complication of procedure or treatment G 8 Transfer to higher level of care L 4 Rising urea or creatinine Trigger Tools

Most frequent: G 7 Complication of procedure or treatment G 4 Readmission within 30 days G 2 Patient Fall L 12 Wound Infection Trigger Tools

G General care S Surgical care Trigger Tools I Intensive care M Medication L Lab tests

E Contributed to or resulted in temporary harm to the patient & required intervention F Contributed to or resulted in temporary harm to the patient & required initial or prolonged hospitalisation G Contributed to or resulted in permanent patient harm H Required intervention to sustain life I Contributed to the patients death Trigger Tools

Case Note Reviews – Examples of Learning • The amount of missing information in records: • Prescription sheets • Nursing records • TPR charts Trigger Tools

Case Note Reviews – Examples of Learning Standard of documentation: • Patient not documented as discharged • Illegible hand writing • Events not documented Trigger Tools

Trigger Tools - Summary • Powerful Tool for identifying events/harm to patients • Time consuming • Form is not intuitive BUT has been adapted • Important to keep a record of the events • The Global Tool is designed for adults • Other tools available e. g. Adverse Drug Events, ITU, Neonatal ICU, Outpatients, Peri-operative, Mental health Trigger Tools

Any Questions? Next Steps? Trigger Tools