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Characterization of Adverse Events Detected in a Large Health Care Delivery System Using an Enhanced Global Trigger Tool over a Five-Year Interval

Authors

  • Donald A. Kennerly M.D., Ph.D.,

    Corresponding author
    1. Office of the Chief Quality Officer, Baylor Health Care System, Baylor Scott and White Health, 8080 N. Central Expressway, Suite 500, Dallas, TX 75206
    • Address correspondence to Donald A. Kennerly, M.D., Ph.D., Office of the Chief Quality Officer, Baylor Health Care System, Baylor Scott and White Health, 8080 N. Central Expressway, Suite 500, Dallas, TX 75206; e-mail: donald.kennerly@baylorhealth.edu.

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  • Rustam Kudyakov M.D.,M.P.H.,

    1. Center for Clinical Effectiveness, Office of the Chief Quality Officer, Baylor Scott and White Health, Dallas, TX
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  • Briget da Graca J.D., M.S.,

    1. Center for Clinical Effectiveness, Office of the Chief Quality Officer, Baylor Scott and White Health, Dallas, TX
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  • Margaret Saldaña R.H.I.A., M.P.H.,

    1. Office of the Chief Quality Officer, Baylor Health Care System, Baylor Scott and White Health, Dallas, TX
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  • Jan Compton R.N., B.S.N., M.S.H.A., C.P.H.Q.,

    1. Office of the Chief Quality Officer, Baylor Health Care System, Baylor Scott and White Health, Dallas, TX
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  • David Nicewander M.S.,

    1. Office of the Chief Quality Officer, Baylor Health Care System, Baylor Scott and White Health, Dallas, TX
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  • Richard Gilder M.S., R.N.-B.C.

    1. Office of the Chief Quality Officer, Baylor Health Care System, Baylor Scott and White Health, Dallas, TX
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Abstract

Objective

To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.

Study Setting

Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.

Study Design

We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.

Data Collection

Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs).

Principal Findings

Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were “preventable/possibly preventable.” Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were “preventable/possibly preventable”; the most common category was “surgical/procedural” (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs.

Conclusions

AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

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