IHI Global Trigger Tool for Measuring Adverse Events (Second Edition, 2009)

Summary

Traditional efforts to detect adverse events have focused on voluntary reporting and tracking of errors. However, public health researchers have established that only 10-20% of errors are ever reported and, of those, 90-95% cause no harm to patients. Hospitals need a more effective way to identify events that do cause harm to patients in order to quantify the degree and severity of harm, and to select and test changes to reduce harm.

The IHI Global Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time. Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes. The Trigger Tool methodology includes a retrospective review of a random sample of patient records using “triggers” (or clues) to identify possible adverse events. Many hospitals have used this tool to identify adverse events, to measure the level of harm from each adverse event, and to identify areas for improvement in their organizations. It is important to note, however, that the IHI Global Trigger Tool is not meant to identify every single adverse event in a patient record. The recommended time limitation for review and the random selection of records are designed to produce a sampling approach that is sufficient for the design of safety work in the hospital.