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An Introduction to the Institute for Healthcare Improvement (IHI)
Trigger Tool Methodology

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What is the Global Trigger Tool?  

The Global Trigger Tool provides more consistent and accurate information about the level of patient harm in your organisation.   Traditional efforts to detect adverse events have focused on voluntary reporting, however as only 10-20% of errors are reported and most cause no harm, this method is not a reliable indicator.   The Global Trigger tool will however complement voluntary reporting systems already in place.  

The Global Trigger Tool is a methodology developed by the Institute of Health care Improvement (IHI) in the USA to identity adverse events (AEs) using medical record reviews. The methodology was originally used to identify adverse drug errors (ADEs) but has since been expanded to encompass all adverse event categories across the hospital

• The tool attempts to quantify actual patient harm, whether or not it was caused by a medical error.   It includes only physical harm and specifically excludes mental or emotional harm.
   

• A focus on harm targets the system and allows the analysis of ‘unintended results’.   It does not focus on individuals so fears of a punitive response are ungrounded.
   

Definitions 

• Adverse Events: Adverse events are any injury (harm) caused by medical management and are independent of the patients’ disease. They may occur despite the correct care being, for example an unforeseen infection or bleeding from an invasive diagnostic procedure.
  
   

• IHI Definition of harm: Unintended physical injury resulting from or contributed by medical care that requires additional monitoring, treatment or hospitalisation or that results in death.
  
   

• Medical Errors: Medical errors are failures in the process of care and have the potential to be harmful, but are not often linked to actual patient harm. For example, a wrong medication given to a patient that does not result in harm.

Categories of Harm recorded

The IHI trigger tool used the National Coordinating Council for Medication Error reporting and Prevention (NCC MERP) Index for recording errors.   This index defines 9 categories of error, but because the IHI Trigger Tool counts only adverse events that result in harm, it excludes the first four categories (A-D) which do not cause harm.

The remaining categories of harm include:

What are Triggers?

Triggers are indicators of potential harm. For example,

• Abnormal laboratory values (INR > 6)

• An abrupt cessation of medication

• Antidotes administered (i.e. naloxone, flumazenil)

• A return to theatre

These are then further investigated to confirm actual harm has occurred.  

The triggers were developed by IHI based on a literature review of adverse events in various areas of the hospital.   These were tested and prioritised and have been adjusted over time to reflect changes in treatments and types of adverse events. 

There are approximately 60 triggers grouped into six modules that relate to more general aspects of care or service areas. The following modules are included:

1. Cares

2. Medication

3. Laboratory

4. Surgical

5. Intensive Care

6. Emergency Department

What is involved?

• The process involves routinely reviewing retrospective medical record for random sample of completed patient admissions.

• Reviews are carried out by teams of trained record reviewers who have a clinical background (usually nurses and pharmacists).

• Each record is reviewed separately by the reviewers to ensure reliability of results.

• The review is carried out according to a standardised, systematic process that limits the time taken to audit each record.

• Any triggers identified are further investigated to confirm whether actual harm has occurred.

• The process is overseen by a senior clinician who authenticates the consensus of the two reviewers.

What results are reported?  

Three main results are reported:

• Adverse events per 1000 patient days

• Adverse events per 100 patient admissions

• Percent admissions with one or more adverse events

This information is typically presented as run charts to reflect a standardised rate of adverse events over time within an organisation.

What are the results used for?

• The primary purpose of using the Global Trigger Tool is as a method for reviewing progress in patient safety.

• Making the results visible and communicating these across the organisation helps to raise awareness about patient safety among staff and patients and provide some impetus to taking action.

• Using the tool does nothing to reduce the rate of harm. The information provided by undertaking the process helps to focus on local interventions that will reduce the rate of adverse events and drive organisational change.

The information produced by the Global Trigger Tool is not intended to be used to benchmark the performance of one organisation, hospital, or clinical area with another. Reviewers with a range of clinical skill and experience undertake the audit process and categorise events which can result in variation.   Standardisation of processes within an organisation is the key to identifying and measuring events over time to support patient safety initiatives. 

The tool and much of the background information, was developed by the IHI. For more detailed information please refer to the Institute of Healthcare Improvement website at http://www.ihi.org/

 Works Acknowledged 

1. Adverse Drug Event Trigger Tool: A Practical Methodology for Measuring Medication-Related Patient Harm. J D Rozich, C R Haraden, R K Resar. 2003, Qual Saf Health Care, pp. 12:194-200.
    

2. Griffin, FA & Resear RK. IHI Global Trigger Tool for Measuring Adverse Events (2nd Ed). Institute for Healthcare Improvement Web Site. [Online] 2009. http://www.ihi.org/NR/rdonlyres/E44B4920-3E5B-4739-9761-8E3A7168AA0E/9696/IHIGlobalTriggerToolWhitePaper2009.pdf.
    

3. Institute for Healthcare Improvement and Premier. Trigger Tool for Measuring Adverse Drug Events. Institute for Healthcare Improvement. [Online] 2004. http://www.ihi.org/NR/rdonlyres/8D970CE4-BF8C-4F35-9BC1-51358FC8B43F/2222/TriggerToolforMeasuringAdverseDrugEventsCorrected1.pdf.

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