scholarly journals Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method

BMJ Open ◽  
2014 ◽  
Vol 4 (5) ◽  
pp. e004879 ◽  
Author(s):  
Hans Rutberg ◽  
Madeleine Borgstedt Risberg ◽  
Rune Sjödahl ◽  
Pernilla Nordqvist ◽  
Lars Valter ◽  
...  
2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
E Scarpis ◽  
S Degan ◽  
D De Corti ◽  
F Mellace ◽  
R Cocconi ◽  
...  

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.


2019 ◽  
Author(s):  
Fingki handayani

Keselamatan pasien dan mutu pelayanan kesehatan yang tinggi adalah tujuan akhir yang selalu diharapkan oleh rumah sakit, manajer, tim penyedia pelayanan kesehatan, pihak jaminan kesehatan, serta pasien, keluarga dan masyarakat. Namun demikian, prinsip “First, do no harm” tidak cukup kuat untuk mencegah berkembangnya masalah keselamatan pasien. Hal ini tercermin dari tingkat dan skala masalah keselamatan pasien sejak terbitnya publikasi “To Err is Human” pada tahun 2000.1 Hingga studi-studi terkini. Di Amerika, hasil studi keselamatan pasien pada akhir tahun 1990-an menemukan angka 3,9% dan 2,7% angka kejadian yang tidak diinginkan (KTD) pada pasien rawat inap.2,3 Dua puluh tahun kemudian, pengukuran dengan Global Trigger Tool menunjukkan bahwa KTD meningkat 10 kali lipat (menjadi 32%).4 Di Indonesia, isu keselamatan pasien mulai dibahas pada tahun 2000, diikuti dengan studi pertama di 15 rumah sakit dengan 4500 rekam medik. Hasilnya menunjukkan bahwa angka KTD sangat bervariasi, yaitu 8,0%-98,2% untuk kesalahan diagnosis dan 4,1%-91,6% untuk kesalahan pengobatan.5 Sejak itu, bukti-bukti tentang keselamatan pasien di Indonesia pun merebak, meskipun belum ada studi nasional hingga saat ini. Kita patut merasa iri dengan negara-negara di Amerika Latin yang telah mempunyai studi Iberoamerican study of adverse events (IBEAS) di 58 rumah sakit dari 5 negara.


2016 ◽  
Vol IV Série (Nº 9) ◽  
pp. 97-106 ◽  
Author(s):  
Ludmila Pierdevara ◽  
Inês Ventura ◽  
Margarida Eiras ◽  
Amélia Gracias ◽  
Carina Silva

2020 ◽  
Vol 102 ◽  
pp. 103473 ◽  
Author(s):  
Ami Hommel ◽  
Martin Magnéli ◽  
Bodil Samuelsson ◽  
Kristina Schildmeijer ◽  
Desirée Sjöstrand ◽  
...  

2019 ◽  
Vol 8 (1) ◽  
pp. e000377 ◽  
Author(s):  
Ellinor Christin Haukland ◽  
Kjersti Mevik ◽  
Christian von Plessen ◽  
Carsten Nieder ◽  
Barthold Vonen

BackgroundThere is no standardised method to investigate death as a patient safety indicator and we need valid and reliable measurements to use adverse events contributing to death as a quality measure.ObjectiveTo investigate the contribution of severe adverse events to death in hospitalised patients and clarify methodological differences using the Global Trigger Tool method on all inpatient deaths compared with a sample of general hospitalised patients.MethodRetrospective records reviewing using the Global Trigger Tool method.ResultsIn 0.3% of hospital admissions, adverse events contribute to inpatient death. Patients who die in hospital have twice the rate of adverse events per 1000 patient days compared with general patients, 76.7 vs 36.5 (p<0.001, RR 2.10, 95% CI 1.79 to 2.47). Patients dying in hospital experience seven times the rate of severe adverse events, 38.4% vs 5.2% (p<0.001, RR 2.10, 95% CI 1.79 to 2.47). For 86 out of 377 inpatient deaths, the adverse event is so severe that it contributes to death. 27.9% of severe adverse events contributing to death originate in primary care. Lower respiratory infections (p<0.001, RR 2.81, 95% CI 1.76 to 4.51), medication harm (p<0.001, RR 5.21, 95% CI 3.04 to 8.94) and pressure ulcers (p=0.04, RR 2.23, 95% CI 1.03 to 4.85) are significantly more frequent for inpatient deaths than in the general sample of hospital patients.ConclusionsPatients dying in hospitals experience seven times the rate of severe adverse events. Reviewing all inpatient death by the Global Trigger Tool method discloses new valid and reliable data of severe adverse events contributing to death which otherwise would be undetected.


2013 ◽  
Vol 7 (1) ◽  
pp. 10 ◽  
Author(s):  
Maria Unbeck ◽  
Kristina Schildmeijer ◽  
Peter Henriksson ◽  
Urban Jürgensen ◽  
Olav Muren ◽  
...  

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