Implementation of Adverse Event Trigger Tool System for Assessing Patient Safety

Despite the importance of patient safety in home-care nursing provided by licensed nurses in patients’ homes, little is known about the nationwide incidence of adverse events in Japan. This article describes the incidence of adverse events among home-care nursing agencies in Japan and investigates the characteristics of agencies that were associated with adverse events. A cross-sectional nationwide self-administrative questionnaire survey was conducted in March 2020. The questionnaire included the number of adverse event occurrences in three months, the process of care for patient safety, and other agency characteristics. Of 9979 agencies, 580 questionnaires were returned and 400 were included in the analysis. The number of adverse events in each agency ranged from 0 to 47, and 26.5% of the agencies did not report any adverse event cases. The median occurrence of adverse events was three. In total, 1937 adverse events occurred over three months, of which pressure ulcers were the most frequent (80.5%). Adjusting for the number of patients in a month, the percentage of patients with care-need level 3 or higher was statistically significant. Adverse events occurring in home-care nursing agencies were rare and varied widely across agencies. The patients’ higher care-need levels affected the higher number of adverse events in home-care nursing agencies.

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Global Trigger Tool methodology to detect adverse events: pilot study at Academic Hospital of Udine

European Journal of Public Health ◽

10.1093/eurpub/ckaa166.522 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

E Scarpis ◽

S Degan ◽

D De Corti ◽

F Mellace ◽

R Cocconi ◽

...

Keyword(s):

Patient Safety ◽

Adverse Events ◽

Academic Hospital ◽

Trigger Tool ◽

Hospital Acquired Infections ◽

Frequent Type ◽

Global Trigger Tool ◽

Clinical Records ◽

Hospital Acquired ◽

Over Time

Abstract Introduction Identification and measurement of adverse events (AEs) is crucial for patient safety in order to monitor them over time and to implement quality improvement programs, testing if they are effective. Global Trigger Tool (GTT) has been proposed as a low-cost method, being also the most effective to detect AEs. This study aims to describe the number of triggers, the rate and level of AEs identified by GTT and the most frequent type of AE. Methods The Italian version of the GTT was used. Ten paper-based clinical records (CRs) randomly selected every 2 weeks were reviewed from January to April 2019 by three independent reviewers (two nurses, one doctor) at the Academic Hospital of Udine. The AEs rates calculated are: AEs per 1,000 patient-days, AEs per 100 admissions, percentage of admissions with an AE. AEs were classified by harm levels according to National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Results CRs reviewed were 80. Mean age of the patients was 69.3±16.4, women were 37.5%. Mean hospitalisation was 16.8±15.3. Nine were the cases of re-hospitalisation within 30 days (11.3%). The total number of trigger was 156. AEs were 31, with at least one AE on 27.5% of admissions, 38.8 AEs per 100 admissions and 23 AEs per 1,000 patient-days. AEs with harm level E, F and H were respectively 5 (16.1%), 24 (77.4%) and 2 (6.5%). The most frequent type of AE were hospital acquired infections with 15 cases (48.4%). Conclusions The most frequent type of AE was the hospital acquired infections. Rates and levels of AEs were higher than other international studies, probably because of the limited number of CRs reviewed. Key messages Global Trigger Tool is an effective method to detect adverse patient safety events in order to monitor them over time. The most frequent type of adverse events was the hospital acquired infections.

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Application of electronic trigger tools to identify targets for improving diagnostic safety

BMJ Quality & Safety ◽

10.1136/bmjqs-2018-008086 ◽

2018 ◽

Vol 28 (2) ◽

pp. 151-159 ◽

Cited By ~ 21

Author(s):

Daniel R Murphy ◽

Ashley ND Meyer ◽

Dean F Sittig ◽

Derek W Meeks ◽

Eric J Thomas ◽

...

Keyword(s):

Adverse Event ◽

Patient Safety ◽

High Risk ◽

Health Systems ◽

Language Processing ◽

Diagnostic Errors ◽

Diagnostic Process ◽

Future Research ◽

Implementation Challenges ◽

Preventable Harm

Progress in reducing diagnostic errors remains slow partly due to poorly defined methods to identify errors, high-risk situations, and adverse events. Electronic trigger (e-trigger) tools, which mine vast amounts of patient data to identify signals indicative of a likely error or adverse event, offer a promising method to efficiently identify errors. The increasing amounts of longitudinal electronic data and maturing data warehousing techniques and infrastructure offer an unprecedented opportunity to implement new types of e-trigger tools that use algorithms to identify risks and events related to the diagnostic process. We present a knowledge discovery framework, the Safer Dx Trigger Tools Framework, that enables health systems to develop and implement e-trigger tools to identify and measure diagnostic errors using comprehensive electronic health record (EHR) data. Safer Dx e-trigger tools detect potential diagnostic events, allowing health systems to monitor event rates, study contributory factors and identify targets for improving diagnostic safety. In addition to promoting organisational learning, some e-triggers can monitor data prospectively and help identify patients at high-risk for a future adverse event, enabling clinicians, patients or safety personnel to take preventive actions proactively. Successful application of electronic algorithms requires health systems to invest in clinical informaticists, information technology professionals, patient safety professionals and clinicians, all of who work closely together to overcome development and implementation challenges. We outline key future research, including advances in natural language processing and machine learning, needed to improve effectiveness of e-triggers. Integrating diagnostic safety e-triggers in institutional patient safety strategies can accelerate progress in reducing preventable harm from diagnostic errors.

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Adverse Event Reporting: Harnessing Residents to Improve Patient Safety

Journal of Patient Safety ◽

10.1097/pts.0000000000000333 ◽

2017 ◽

Vol 16 (4) ◽

pp. 294-298 ◽

Cited By ~ 6

Author(s):

Sarah E. Tevis ◽

Ryan K. Schmocker ◽

Tosha B. Wetterneck

Keyword(s):

Adverse Event ◽

Patient Safety ◽

Improve Patient Safety ◽

Adverse Event Reporting ◽

Event Reporting ◽

Improve Patient

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Menerapkan Kebijakan Untuk Keselamatan Pasien

10.31227/osf.io/89dzp ◽

2019 ◽

Author(s):

Eva Eryanti Harahap

Keyword(s):

Adverse Event ◽

Patient Safety ◽

Medical Error ◽

Near Miss

Keselamatan pasien itu sangat penting dan menjadi tuntutan bagi rumah sakit untuk melaksanakannya karena rumah sakit sangat berpotensi terjadinya risiko berupa kesalahan medis (medical error), kejadian yang tidak diharapkan (adverse event) dan nyaris terjadi (near miss). Untuk itu, , Kementerian Kesehatan Republik Indonesia telah menerbitkan Panduan Nasional Keselamatan Pasien (Patient Safety) di Rumah Sakit tahun 2008 yang terdiri dari 7 standar, yaitu: 1) hak pasien, 2) mendidik pasien dan keluarga, 3) keselamatan pasien dan kesinambungan pelayanan, 4) penggunaan metode peningkatan kinerja untuk melakukan evaluasi dan program, 5) peningkatan keselamatan pasien, 6)mendidik staf tentang keselamatan kerja, dan 7) komunikasi merupakan kunci bagi staf untuk mencapai keselamatan pasien. Dan agar tercapainya standar tersebut Panduan Nasional menganjurkan 7 Langkah Menuju Keselamatan Pasien Rumah Sakit, yaitu: 1) bangun kesadaran akan keselamatan pasien, 2) pimpin staf, 3) integrasikan aktivitas pengelolaan risiko, 4) kembangkan sistem pelaporan, 5) libatkan dan berkomunikasi dengan pasien, 6) belajar dari berbagai pengalaman tentang keselamatan pasien, dan 7) cegah cedera melalui implementasi sistem keselamatan pasien

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PATIENT SAFETY SEBAGAI SISTEM PENCEGAH KTD DAN PENINGKATAN KUALITAS PELAYANAN RUMAH SAKIT

10.31219/osf.io/89kns ◽

2019 ◽

Author(s):

Minda Ihsaniah Nasution

Keyword(s):

Adverse Event ◽

Patient Safety ◽

Underlying Disease ◽

Near Miss

Kesalahan yang terjadi dalam proses asuhan keperawatan akan berpotensi mengakibatkan cedera pada pasien, bisa berupa Near Miss atau Adverse Event (Kejadian Tidak Diharapkan/KTD).Adverse Event atau Kejadian Tidak Diharapkan (KTD) merupakan suatu kejadian yang mengakibatkan cedera yang tidak diharapkan pada pasien karena suatu tindakan (commission) atau tidak mengambil tindakan yang seharusnya diambil (omission), dan bukan karena “underlying disease” atau kondisi pasien.

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Analysis of Medication-Related Deaths in Denmark

ISRN Public Health ◽

10.1155/2013/214893 ◽

2013 ◽

Vol 2013 ◽

pp. 1-5

Author(s):

Lars Dahlgaard Hove ◽

Johannes Bock ◽

Jens Krogh Christoffersen

Keyword(s):

Internal Medicine ◽

Adverse Event ◽

Patient Safety ◽

Retrospective Study ◽

Orthopaedic Surgery ◽

Safety Measures ◽

Danish Patient ◽

Wrong Drug ◽

Closed Claims ◽

Future Patient

Objective. To investigate the circumstances associated with medication-related deaths. Design and Setting. This retrospective study investigated closed claims concerning medication-related deaths from 1996 to 2008 registered by the Danish Patient Insurance Association (DPIA). Results. A total of 80 were patients registered as having died because of an adverse event or error associated with a medication, and 37 of these cases were considered to have been preventable. The circumstances of the 37 deaths are described in detail in this report. Orthopaedic surgery, anaesthesiology, and internal medicine were the specialties involved in the majority of the deaths. Incorrect dosing was the cause of 17 deaths, and the use of the wrong drug caused 11 deaths. The administration of a drug despite a known allergy/intolerance or contraindication caused 6 deaths. Other 5 deaths were caused by anticoagulation medications. Methotrexate given daily by mistake caused 2 deaths. Conclusion. This study describes the circumstances of 37 preventable deaths caused by medication. Drug administration despite a known allergy, opioids, sedative, anticonvulsive medicine, and incorrect dosing and incorrect use of anticoagulants are the most important areas to be addressed in the development of future patient safety measures to reduce patient deaths caused by or related to medications.

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