IHI Global Trigger Tool for Measuring Adverse Events 2ed May 2009

Posted on May 18, 2009. Filed under: Clin Governance / Risk Mgmt / Quality, Health Systems Improvement, Patient Safety | Tags: , |

Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009.

“This Second Edition of the IHI Global Trigger Tool for Measuring Adverse Events white paper contains no substantive changes to the overall methodology or process for review. Clarifications have been made to some text and trigger definitions. Experienced reviewers will note that there are changes to the list of triggers. ”

“Traditional efforts to detect adverse events have focused on voluntary reporting and tracking of errors. However, public health researchers have established that only 10 to 20 percent of errors are ever reported and, of those, 90 to 95 percent 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.”… continues on the website


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