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The Role of Trigger Tools in Detecting Adverse Events in Hospitalized Children: Filling in the Blanks Anne Matlow MD FRCPC Medical Director, Patient Safety Hospital for Sick Children, Toronto Associate Director, Centre for Patient Safety University of Toronto NICHQ 2010 DISCLOSURE I am Canadian And I won’t rub it in!!! The Role of Trigger Tools in Detecting Adverse Events in Hospitalized Children: Filling in the Blanks Anne Matlow MD FRCPC Medical Director, Patient Safety Hospital for Sick Children, Toronto Associate Director, Centre for Patient Safety University of Toronto NICHQ 2010 Trigger tool 9 year old girl. Fell out of bed. Presented to ER with decreased level of consciousness and hypertension. Admitted to PICU. Management focused on determining cause of lethargy (CT, MRI) and treating hypertension. Nephrology consulted when BP still elevated. Elicited history from Mom of periorbital edema. Diagnosis post- infectious glomerulonephritis with hypertension and encephalopathy. On review, proteinuria and hematuria present on admission. Improved on antihypertensives and low sodium diet. Country Charts Reviewed Year Incidence of AE Preventable Canada 3,745 2000 7.5% 37% Denmark 1,097 1999 9.0% 40.4% New Zealand 6,579 1998 12.9% 37% England 1,014 1998 11.7% 50% Australia 14,000 1992 16.6% 51% USA (Utah & Colorado) 15,000 1992 2.9% - USA (NY) 30,121 1984 3.7% 58% SCREENING/EXPLICIT CRITERIA 1. Unplanned admission pre 2. Unplanned readmit within 12 months 3. Hospital incurred injury 4. Adverse drug event 5. Unplanned transfer to ICU 6. Unplanned transfer to another acute care hosp 7. Unplanned return to OR 8. Unplanned removal, injury or repair intra-operatively 9. Other patient complications 10. New neurological deficit 11. Unexpected death 12. Inappropriate discharge home 13. Cardiac/ resp arrest / low APGAR score 14. Injury related to delivery or abortion 15. Hospital acquired infection/ sepsis 16. Documented dissatisfaction with care 17. Documentation or correspondence re litigation 18. Any other undesirable outcomes Detecting Adverse Events Method AE/1000 admissions Incident Reports (2-8%) Retrospective Chart Review Stimulated Voluntary Reports Automated Flags Daily chart review Automated Flags and Daily review 5 30 30 55* 85 130* *triggers Jha J Am Med Inf Assoc 1998;5:305 O'Neil Ann Int Med 1993;119:370 Original slide courtesy of Dr Philip Hebert • Manual – Paper-based retrospective chart review • Semi-automated – Screening electronically + review manually – Prospective, Concurrent, Retrospective • Fully automated – Screening + reviewing electronically – Only some types of AEs • e.g. INR>6 in pts on warfarin, ICD-9 codes – Not if implicit judgement is required Voluntary reporting and computerized surveillance not as good as chart review Manual Chart Review Computerized Surveillance Voluntary Reporting 67 331 3 20 205 Classen DC, Pestotnik S. Evans S et al. Computerized surveillance of adverse drug events in hospitalized patients. JAMA. 1991;226:2847 Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review Sari BMJ 2007;334:79 • 324 patient safety incidents were identified in 230/1006 admissions (22.9%; 95% CI 20.3% to 25.5%). • 270 (83%) patient safety incidents were identified by case note review (TT) only, • 21 (7%) by the routine reporting system only, and 33 (10%) by both methods. – TT 12x more sensitive than routine reporting system Trigger Tool 2 stage Review TRIGGERS ADVERSE EVENTS Rate of Adverse Events without using Trigger Tools –All adverse events: ~1.0-3 / 100 patients (Miller Pediatrics 2003 and 2004; Slonim Pediatrics 2003; Woods Pediatrics 2005; ) –Adverse drug events: • True: 2.1-11/ 100 admissions • Potential: ADE 14.6/ 100 admissions • 22-60% preventable (Kaushal JAMA 2001; Holdsworth APAM 2003; Kunac Pediatric Drugs 2009) Adverse Events in the NICU Sharek et al. Pediatrics. 2006:118:1332-1340 n=554 74 per 100 admissions of which 56% preventable Incidence of Adverse Events and Negligence in Hospitalized Patients Brennan NEJM 1991 Adverse events and preventable adverse events in children Woods Peds 2005:115:155 Adverse events and preventable adverse events in children Woods D. Pediatrics. 2005 Jan;115:155-60. Quality in Australian Health Care Study Wilson Med J Aust 1995 Diagnostic errors are common cause of adverse events NY 1984 Utah/Col 1992 Australia 1992 NZ 1998 UK 1999 Canada 2001 Sweden 2003 AE rate Diagnostic 3.7% 2.9% 16.6% 13.1% 10.8% 7.5% 14.2% 7% 6.9% 13.3% 8% 4.2% 10.6% 11.3% De Vries QSHC 2008; Soop IJQHC 2009 DIAGNOSTIC ERROR Graber Arch Int Med 2005 Occurrences for which diagnosis was 1. Unintentionally delayed (sufficient info was available earlier), 2. Wrong (another diagnosis was made before the correct diagnosis), or 3. Missed (no diagnosis was ever made), as judged from the eventual appreciation of more definitive information CAN TRIGGER TOOLS HELP US IDENTIFY DIAGNOSTIC ERROR? Sensitivity and Specificity of the Canadian Paediatric Trigger Tool Adverse Event Trigger Yes Yes 78 No 283 Total 361 (60%) No 11 219 230 Total 89 (15%) 502 591 89 patients experienced at least 1 AE Clinical Care Process vs #AE Surgical Medical Procedure Diagnostic Clinical management 50 16 14 10 Drug/Fluid Fractures System Issue Other Total number of AEs 10 1 1 21 123 Clinical Care Process vs #AE Surgical Medical Procedure Diagnostic Clinical management 50 16 14 10 Drug/Fluid Fractures System Issue Other Total number of AEs 10 1 1 21 123 11.4% of adverse events were diagnostic Distribution of AEs by Age Category Surg D/ FL Other 4 Clin Man 9 2 12 0-28 d 18 Med Proc 11 Diag 29- 365 d 11 2 4 0 1 9 366 d5 yr 14 0 3 0 6 1 >5 yr 7 3 3 1 1 1 Total # AEs 50 16 14 10 10 23 DIAGNOSTIC ERROR Delayed diagnosis of post streptococcal glomerulonephritis in 9 year old. Presented with hypertension and decreased level of consciousness. Work up focused on neurological findings. Diagnosis actually glomerulonephritis with hypertension and encephalopathy. Delay in initiating appropriate treatment. Improved on antihypertensives and low sodium diet. CAN TRIGGER TOOLS HELP US IDENTIFY DIAGNOSTIC ERROR? METHODOLOGY DEPENDENT CPTT Two types of Second stage review Focused Chart Review - Facilitates standardized second phase chart review - More efficient - Better to show improvement over time? Complete Chart Review - ? Finds more AEs? - ? Can find different AEs eg diagnostic error? FOCUSING ON DIAGNOSTIC ERROR WILL FILL IN A BLANK