Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward

BMJ Quality & Safety
Brian M WongKaveh Shojania

Abstract

Retrospective record review using trigger tools remains the most widely used method for measuring adverse events (AEs) to identify targets for improvement and measure temporal trends. However, medical records often contain limited information about factors contributing to AEs. We implemented an augmented trigger tool that supplemented record review with debriefing front-line staff to obtain details not included in the medical record. We hypothesised that this would foster the identification of factors contributing to AEs that could inform improvement initiatives. A trained observer prospectively identified events in consecutive patients admitted to a general medical ward in a tertiary care academic medical centre (November 2010 to February 2011 inclusive), gathering information from record review and debriefing front-line staff in near real time. An interprofessional team reviewed events to identify preventable and potential AEs and characterised contributing factors using a previously published taxonomy. Among 141 patients, 14 (10%; 95% CI 5% to 15%) experienced at least one preventable AE; 32 patients (23%; 95% CI 16% to 30%) experienced at least one potential AE. The most common contributing factors included policy and proce...Continue Reading

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Citations

Jul 8, 2015·BMJ Quality & Safety·Charles Vincent, Rene Amalberti
Feb 16, 2018·International Journal of Clinical Pharmacy·Guillaume HébertUNKNOWN IATRIGGER Working Group
Jun 7, 2018·British Journal of Clinical Pharmacology·Maria das Dores Graciano SilvaAntonio Luiz Pinho Ribeiro
May 5, 2017·Creative Nursing·Christine S Gipson
May 28, 2019·BMJ Quality & Safety·Adam P Johnson, Rajesh Aggarwal
Jul 5, 2019·BMJ Quality & Safety·Alan J ForsterChantal Backman
Feb 19, 2020·BMJ Quality & Safety·Kaveh G Shojania, Perla J Marang-van de Mheen
Mar 6, 2018·International Journal of Health Care Quality Assurance·Chantal BackmanAlan J Forster
Jan 22, 2021·BMJ Quality & Safety·Emily L Aaronson, David W Bates
Mar 14, 2020·Journal of Patient Safety·Daniel J FranceMartin L Blakely
Jul 15, 2018·Pediatrics·David C StockwellUNKNOWN GAPPS Study Group
Dec 30, 2021·Journal for Healthcare Quality : Official Publication of the National Association for Healthcare Quality·Klaus G NetherLauren Yager

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Methods Mentioned

BETA
X-ray

Software Mentioned

Excel
IHI Global Trigger Tool
Access

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