Assessment of adverse events in medical care: lack of consistency between experienced teams using the global trigger tool

BMJ Quality & Safety
Kristina SchildmeijerJoep Perk

Abstract

Many patients are harmed as the result of healthcare. A retrospective structured record review is one way to identify adverse events (AEs). One such review approach is the global trigger tool (GTT), a consistent and well-developed method used to detect AEs. The GTT was originally intended to be used for measuring data over time within a single organisation. However, as the method spreads, it is likely that comparisons of GTT safety outcomes between hospitals will occur. To evaluate agreement in judgement of AEs between well-trained GTT teams from different hospitals. Five teams from five hospitals of different sizes in the southeast of Sweden conducted a retrospective review of patient records from a random sample of 50 admissions between October 2009 and May 2010. Inter-rater reliability between teams was assessed using descriptive and κ statistics. The five teams identified 42 different AEs altogether. The number of identified AEs differed between the teams, corresponding to a level of AEs ranging from 27.2 to 99.7 per 1000 hospital days. Pair-wise agreement for detection of AEs ranged from 88% to 96%, with weighted κ values between 0.26 and 0.77. Of the AEs, 29 (69%) were identified by only one team and not by the other four...Continue Reading

Citations

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