Detection of adverse events in surgical patients using the Trigger Tool approach
Detection of adverse events in surgical patients using the Trigger Tool approach
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DOI：
10.1136/qshc.2007.025080
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发表时间：
2008-08-01
影响因子：
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通讯作者：
Classen, D. C.
中科院分区：
文献类型：
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作者：
Griffin, F. A.;Classen, D. C.
背景：大多数关于医疗保健并发症的研究都认为手术是导致受伤或死亡的复杂护理总体负担的主要因素。事实上，在这些研究中，手术不良事件占所有不良事件的二分之一到四分之三。尽管当前重点关注提高医疗质量和安全，但只有少数质量改进工作集中在手术上。本研究报告了触发工具的开发和测试，该工具用于检测住院手术患者中的不良事件。方法：医疗保健改善研究所 (IHI) 不再依赖传统的自愿报告来进行安全结果测量，例如事件报告、手术同行评审或发病率和死亡率会议，而是采用了一种新方法来检测手术不良事件 (SAE)。这种方法通常被称为“触发工具”，使用已在许多护理领域开发和实施的回顾性记录审查形式来识别不良事件。结果：在为期 12 个月的 IHI 围手术期安全协作中，11 家医院自愿提交了外科住院患者记录审查的数据。在 854 名患者中，在 125 份记录中检测到 138 种严重不良事件，每 100 名患者中检测到 16 种严重不良事件，或14.6% 的患者；其中 61 例 (44%) 事件导致住院时间延长或再次入院，12 例 (8.7%) 事件需要挽救生命或导致永久性伤害或死亡。医院审查小组口头报告称，触发工具审查过程中发现的大多数事件尚未通过任何其他现有机制检测或报告。 结论：IHI 手术触发工具可以提供一种实用、易于使用的方法来检测接受手术的患者的安全问题；它不仅可以作为估计组织中不良事件发生频率的基础，还可以作为确定旨在减少手术患者不良事件的干预措施的影响的基础。
Background: Most studies of healthcare complications identify surgery as a major contributor to the overall burden of complicated care that leads to injury or death. Indeed, surgical adverse events account for one-half to three-quarters of all adverse events in these studies. Despite the intensive current focus on improving medical quality and safety, only a minority of quality improvement efforts are focused on surgery. This study reports on the development and testing of a Trigger Tool to detect adverse events among patients undergoing inpatient surgery.Methods: Rather than relying on traditional voluntary reporting for safety outcome measures such as incident reports, surgical peer review, or morbidity and mortality conferences, the Institute for Healthcare Improvement (IHI) has employed a new method for the detection of surgical adverse events (SAEs). This approach, commonly referred to as the "Trigger Tool'', identifies adverse events using a form of retrospective record review that has been developed and implemented in many areas of care.Results: During a 12-month IHI Perioperative Safety Collaborative, 11 hospitals voluntarily submitted data from surgical inpatient record reviews. In 854 patients, 138 SAEs were detected in 125 records for a rate of 16 SAEs per 100 patients or 14.6% of patients; 61 (44%) of these events contributed to increased length of stay or readmission and 12 (8.7%) events required life-saving intervention or resulted in permanent harm or death. Hospital review teams reported verbally that most of the events identified during the Trigger Tool review process had not been detected or reported via any other existing mechanism.Conclusions: The IHI Surgical Trigger Tool may offer a practical, easy-to-use approach to detecting safety problems in patients undergoing surgery; it can be the basis not only for estimating the frequency of adverse events in an organisation, but also determining the impact of interventions that focus on reducing adverse events in surgical patients.