In the last 10 years, we unfortunately have not been able to show that our efforts to decrease patient harm from adverse events have been successful. Therefore, the search for new strategies continues.
As part of that effort, I attended the second annual Indiana Patient Safety Summit and found David Claussen, M.D., from the University of Utah gave the most interesting presentation.
Dr. Claussen presented the global trigger tool (GTT) as a better way to detect adverse events in health care. The tool has been shown to be more sensitive in detecting adverse events and much better than current quality measures, such as those offered by the Agency for Healthcare Research and Quality.
The GTT has been promoted by the Institute for Healthcare Improvement (IHI) and successfully used by a number of health care facilities to decrease adverse events over time. It can be used concurrently or retrospectively.
The GTT process involves: 1) developing a list of triggers, 2) reviewing the chart for presence of triggers, 3) determining if an adverse event occurred, 4) deciding if harm occurred and assigning a level of harm, 5) reporting and tracking adverse events over time, and 6) changing training, procedures, equipment or personnel if the adverse event was determined to be preventable.
Examples of triggers include: medication error, unplanned return to surgery, blood transfusion and post-op infection. Adverse events increase the risk of death and additional adverse events while contributing to longer hospital stays, hospital readmissions, further procedures, higher costs, disability – and more.
The GTT outlined by Dr. Claussen appears to be a more effective way to diminish adverse events and harm to our patients. Find more on this tool on the IHI website.