PMID- 24628436
OWN - NLM
STAT- MEDLINE
DCOM- 20141128
LR  - 20240322
IS  - 1475-6773 (Electronic)
IS  - 0017-9124 (Print)
IS  - 0017-9124 (Linking)
VI  - 49
IP  - 5
DP  - 2014 Oct
TI  - Characterization of adverse events detected in a large health care delivery 
      system using an enhanced global trigger tool over a five-year interval.
PG  - 1407-25
LID - 10.1111/1475-6773.12163 [doi]
AB  - OBJECTIVE: To report 5 years of adverse events (AEs) identified using an enhanced 
      Global Trigger Tool (GTT) in a large health care system. STUDY SETTING: Records 
      from monthly random samples of adults admitted to eight acute care hospitals from 
      2007 to 2011 with lengths of stay >/=3 days were reviewed. STUDY DESIGN: We 
      examined AE incidence overall and by presence on admission, severity, stemming 
      from care provided versus omitted, preventability, and category; and the overlap 
      with commonly used AE-detection systems. DATA COLLECTION: Professional nurse 
      reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and 
      AEs. Medical record/account numbers were matched to identify overlapping 
      voluntary reports or AHRQ Patient Safety Indicators (PSIs). PRINCIPAL FINDINGS: 
      Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 
      discharges, and 32.1 percent of patients with >/=1 AE. Of 1,300 
      present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP 
      level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 
      hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were 
      "preventable/possibly preventable"; the most common category was 
      "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 
      percent of encounters with hospital-acquired AEs. CONCLUSIONS: AEs are common and 
      potentially amenable to prevention. GTT-identified AEs are seldom caught by 
      commonly used AE-detection systems.
CI  - (c) Health Research and Educational Trust.
FAU - Kennerly, Donald A
AU  - Kennerly DA
AD  - Office of the Chief Quality Officer, Baylor Health Care System, Baylor Scott and 
      White Health, 8080 N. Central Expressway, Suite 500, Dallas, TX 75206.
FAU - Kudyakov, Rustam
AU  - Kudyakov R
FAU - da Graca, Briget
AU  - da Graca B
FAU - Saldana, Margaret
AU  - Saldana M
FAU - Compton, Jan
AU  - Compton J
FAU - Nicewander, David
AU  - Nicewander D
FAU - Gilder, Richard
AU  - Gilder R
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
DEP - 20140313
PL  - United States
TA  - Health Serv Res
JT  - Health services research
JID - 0053006
SB  - IM
CIN - Health Serv Res. 2014 Oct;49(5):1401-6. PMID: 25255819
MH  - Adult
MH  - Delivery of Health Care, Integrated/*statistics & numerical data
MH  - Drug-Related Side Effects and Adverse Reactions/*epidemiology
MH  - Humans
MH  - Incidence
MH  - Length of Stay/*statistics & numerical data
MH  - Medical Errors/*statistics & numerical data
MH  - Medical Records/*statistics & numerical data
MH  - Models, Statistical
MH  - Patient Safety/*statistics & numerical data
MH  - *Quality Indicators, Health Care
MH  - Retrospective Studies
MH  - Texas/epidemiology
PMC - PMC4213042
OTO - NOTNLM
OT  - Adverse events
OT  - Global Trigger Tool
EDAT- 2014/03/19 06:00
MHDA- 2014/12/15 06:00
PMCR- 2015/10/01
CRDT- 2014/03/18 06:00
PHST- 2014/03/18 06:00 [entrez]
PHST- 2014/03/19 06:00 [pubmed]
PHST- 2014/12/15 06:00 [medline]
PHST- 2015/10/01 00:00 [pmc-release]
AID - 10.1111/1475-6773.12163 [doi]
PST - ppublish
SO  - Health Serv Res. 2014 Oct;49(5):1407-25. doi: 10.1111/1475-6773.12163. Epub 2014 
      Mar 13.