Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method

Rutberg, Hans; Risberg, Madeleine Borgstedt; Sjödahl, Rune; Nordqvist, P; Valter, Lars; Nilsson, Lena

doi:10.1136/bmjopen-2014-004879

Cited by 79 publications

(109 citation statements)

References 16 publications

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“…Concerning the rate of AEs, the results found in our study are higher than those found in other studies: Landrigan et al (2010), Rutberg et al (2014), Rozenfeld, Giordani, and Coelho (2013) Classen et al (2011), the rate of 25.1 AEs per 100 admissions found by Landrigan et al (2010), and the rate of 14.5 AEs per 100 admissions found by Hwang et al (2014). Although the rate of AEs found in this study (31.1%) is slightly lower than that found by Classen et al (2011), 33.3%, it is higher than the rates reported by Landrigan et al (2010), 18.1%, Hwang et al (2014), 7%, and Rutberg et al (2014), 20.5%.…”

Section: Resultscontrasting

confidence: 57%

“…Although the rate of AEs found in this study (31.1%) is slightly lower than that found by Classen et al (2011), 33.3%, it is higher than the rates reported by Landrigan et al (2010), 18.1%, Hwang et al (2014), 7%, and Rutberg et al (2014), 20.5%. The significant differences found between the results from the various studies could have been influenced by several factors, such as the organizational structure, the hospital's safety culture, the type of inpatients, the context where the study was carried out, the review process, and the reviewers' training.…”

Section: Resultscontrasting

confidence: 54%

“…The GTT showed a higher reliability in the identification of AEs in. In Sweden, Rutberg et al (2014) conducted an observational retrospective study to identify and compare the incidence of AEs, using two methods: the GTT and the voluntary reporting system. The authors concluded that the GTT allows identifying a higher number of AEs than the voluntary reporting system, and that health institutions should use a set of useful tools to identify AEs in order to substantially reduce the costs related to the prevention of AEs.…”

Section: Methodsmentioning

confidence: 99%

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An experience with the Global Trigger Tool for the study of adverse events in a medical ward

et al. 2016

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Resumo Resumen R E S E A R C H P A P E R ( O R I G I N A L )An experience with the Global Trigger Tool for the study of adverse events in a medical ward Uma experiência com a Global Trigger Tool no estudo dos eventos adversos num serviço de medicina Una experiencia con la Global Trigger Tool en el estudio de eventos adversos en un servicio de medicina Ludmila Pierdevara*; Inês Margarida Ventura**; Margarida Eiras***; Amélia Maria Brito Gracias****; Carina Soares da Silva***** Background: Health care provision is associated with adverse events (AEs) which harm hospitalized patients. Objectives: To study AEs in a medical ward. Methodology: A quantitative, descriptive, observational and retrospective study was conducted from 1 September 2014 to 31 December 2014 in a medical ward of the Algarve Hospital Center. The instrument used to identify the AEs was the Global Trigger Tool (GTT). All the patients who were discharged between 1 January 2014 and 30 September 2014 were listed.Results: The interrater agreement concerning the AE classification, using the Kappa value, proved to be perfect. A total of 278 triggers were identified, of which 124 resulted in AEs: 44.6% of AEs occurred during the hospitalization, and 9.4% of the patients presented AEs at the moment of admission. We found a total of 62.63 AEs per 1,000 patient days, 137.8 AE per 100 admissions, and one AE in 31.1% of the cases during hospitalization. Conclusion:The GGT proved to be a useful tool to analyze AEs in hospital settings.

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Section: Resultscontrasting

confidence: 57%

Section: Resultscontrasting

confidence: 54%

Section: Methodsmentioning

confidence: 99%

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An experience with the Global Trigger Tool for the study of adverse events in a medical ward

et al. 2016

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“…A study using the Global Trigger Tool developed by the Institute for Healthcare Improvement provided a best estimate of 16% as the baseline rate for CD. 7 A total of 2000 hospitalizations were planned to be included to have a power of at least 80% to detect a 25% reduction in the annual incidence of CD with a 2-tailed type I error rate of 0.05. Comparisons of dichotomous event rates were made using chi square tests at a 2-tailed level for significance of 0.05.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Bedside Interdisciplinary Rounds on Length of Stay and Complications

Dunn

Reyna

Radbill

et al. 2017

Journal of Hospital Medicine

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BACKGROUND: Communication among team members within hospitals is typically fragmented. Bedside interdisciplinary rounds (IDR) have the potential to improve communication and outcomes through enhanced structure and patient engagement. OBJECTIVE: To decrease length of stay (LOS) and complications through the transformation of daily IDR to a bedside model. DESIGN: Controlled trial. SETTING: 2 geographic areas of a medical unit using a clinical microsystem structure. PATIENTS: 2005 hospitalizations over a 12-month period. INTERVENTIONS: A bedside model (mobile interdisciplinary care rounds [MICRO]) was developed. MICRO featured a defined structure, scripting, patient engagement, and a patient safety checklist. MEASUREMENTS: The primary outcomes were clinical deterioration (composite of death, transfer to a higher level of care, or development of a hospital-acquired complication) and length of stay (LOS). Patient safety culture and perceptions of bedside interdisciplinary rounding were assessed pre-and postimplementation.RESULTS: There was no difference in LOS (6.6 vs 7.0 days, P = 0.17, for the MICRO and control groups, respectively) or clinical deterioration (7.7% vs 9.3%, P = 0.46). LOS was reduced for patients transferred to the study unit (10.4 vs 14.0 days, P = 0.02, for the MICRO and control groups, respectively). Nurses and hospitalists gave significantly higher scores for patient safety climate and the efficiency of rounds after implementation of the MICRO model. LIMITATIONS:The trial was performed at a single hospital.CONCLUSIONS: Bedside IDR did not reduce overall LOS or clinical deterioration. Future studies should examine whether comprehensive transformation of medical units, including co-leadership, geographic cohorting of teams, and bedside interdisciplinary rounding, improves clinical outcomes compared to units without these features.

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“…Tanto os erros como os eventos adversos podem implicar em aumento do tempo de internação, custos assistenciais e muitas vezes, encargos jurídicos (4) . Ao entender a relação da ocorrência dos eventos adversos com os resultados assistenciais, a Aliança Mundial para a Segurança do Paciente foi criada, no intuito de estabelecer metas e protocolos mundiais de atendimento voltados à segurança (3) .…”

Section: Introductionunclassified

Erros E Eventos Adversos: A Interface Com a Cultura De Segurança Dos Profissionais De Saúde

Souza¹,

Kawamoto²,

Oliveira³

et al. 2015

Cogitare Enferm.

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RESUMO:Estudo descritivo com abordagem quantitativa, que objetivou analisar a cultura de segurança em relação aos erros e eventos adversos, na percepção de profissionais de saúde. Foi realizado entre abril e junho de 2014 em três unidades de um hospital de ensino do sul do Brasil. Participaram 71 profissionais de saúde, que responderam ao questionário "Hospital Survey on Patient Safety Culture". A análise ocorreu por meio de estatística descritiva das dimensões que tratam da cultura de segurança em relação à ocorrência de erros e eventos adversos do instrumento. A maioria dos participantes demonstrou percepção de cultura de segurança desfavorável à comunicação sobre as falhas assistenciais e apontou para cultura punitiva ainda presente na instituição, o que pode justificar a quantidade reduzida de notificação de falhas. Conclui-se que há necessidade de disseminação da cultura não punitiva na organização, para que os erros e eventos adversos possam ser notificados, analisados e corrigidos. DESCRITORES: Segurança do paciente; Cultura organizacional; Erros médicos; Enfermagem. ERROS E EVENTOS ADVERSOS: A INTERFACE COM A CULTURA DE SEGURANÇA DOS PROFISSIONAIS DE SAÚDE ERRORES Y EVENTOS ADVERSOS: LA INTERFAZ CON LA CULTURA DE SEGURIDAD DE LOS PROFESIONALES DE SALUDRESUMO: Estudio descriptivo con abordaje cuantitativo, cuyo objetivo fue analizar la cultura de seguridad acerca de errores y eventos adversos, en la percepción de profesionales de salud. Fue realizado entre abril y junio de 2014 en tres unidades de un hospital de enseñanza del sur de Brasil. Participaron 71 profesionales de salud, que contestaron al cuestionario Hospital Survey on Patient Safety Culture. El análisis ocurrió por medio de estadística descriptiva de las dimensiones que abordan la cultura de seguridad acerca de la ocurrencia de errores y eventos adversos del instrumento. La mayoría de los participantes demostró percepción de cultura de seguridad desfavorable a la comunicación sobre los errores asitenciales y apuntó para cultura punitiva todavía existente en la institución, lo que puede justificar la cantidad reducida de notificación de errores. Se concluye que hay necesidad de diseminación de la cultura no punitiva en la organización, para que los errores y eventos adversos puedan ser notificados, analizados y corregidos.

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Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method

Cited by 79 publications

References 16 publications

An experience with the Global Trigger Tool for the study of adverse events in a medical ward

An experience with the Global Trigger Tool for the study of adverse events in a medical ward

The Impact of Bedside Interdisciplinary Rounds on Length of Stay and Complications

Erros E Eventos Adversos: A Interface Com a Cultura De Segurança Dos Profissionais De Saúde

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