Anne Matlow MD FRCPC Medical Director, Patient Safety Hospital for Sick Children, Toronto

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%

1. Unplanned admission pre2. Unplanned readmit within

12 months3. Hospital incurred injury4. Adverse drug event5. Unplanned transfer to ICU6. Unplanned transfer to

another acute care hosp7. Unplanned return to OR8. Unplanned removal, injury

or repair intra-operatively9. Other patient complications

10.New neurological deficit11.Unexpected death12. Inappropriate discharge home13.Cardiac/ resp arrest / low

APGAR score14. Injury related to delivery or

abortion15.Hospital acquired infection/

sepsis16.Documented dissatisfaction

with care17.Documentation or

correspondence re litigation18.Any other undesirable

outcomes

SCREENING/EXPLICIT CRITERIA

Detecting Adverse Events

Method AE/1000 admissions

Incident Reports (2-8%) 5Retrospective Chart Review 30Stimulated Voluntary Reports 30Automated Flags 55*Daily chart review 85Automated Flags and Daily review 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 Manual Chart ReviewReview

367

Computerized Computerized SurveillanceSurveillance

331 205

20

Voluntary Voluntary ReportingReporting

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 ReviewTrigger 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=55474 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 StudyWilson Med J Aust 1995

Diagnostic errors are commoncause of adverse events

De Vries QSHC 2008; Soop IJQHC 2009

AE rate DiagnosticNY 1984 3.7% 7%Utah/Col 1992 2.9% 6.9%Australia 1992 16.6% 13.3%NZ 1998 13.1% 8%UK 1999 10.8% 4.2%Canada 2001 7.5% 10.6%Sweden 2003 14.2% 11.3%

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 No Total

Yes 78 283 361 (60%)

No 11 219 230

Total 89 (15%) 502 591

89 patients experienced at least 1 AE

Clinical Care Process vs #AE

Surgical 50

Medical Procedure 16

Diagnostic 14

Clinical management 10

Drug/Fluid 10

Fractures 1

System Issue 1

Other

Total number of AEs

21

123

Clinical Care Process vs #AE

Surgical 50

Medical Procedure 16

Diagnostic 14

Clinical management 10

Drug/Fluid 10

Fractures 1

System Issue 1

Other

Total number of AEs

21

123

11.4% of adverse events were diagnostic

Distribution of AEs by Age Category

Surg Med Proc

Diag Clin Man

D/ FL Other

0-28 d 18 11 4 9 2 12

29- 365 d 11 2 4 0 1 9

366 d-

5 yr14 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