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Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger
James M Naessens1, Thomas J O'Byrne, Matthew G Johnson
1Division of Health Care Policy & Research, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA. naessens@mayo.edu
Objective:
To determine the inter-rater reliability of the Institute for Healthcare Improvement's Global Trigger Tool (GTT) in a practice setting, and explore the value of individual triggers.
Design:
Prospective assessment of application of the GTT to monthly random samples of hospitalized patients at four hospitals across three regions in the USA.
Setting:
Mayo Clinic campuses are in Minnesota, Arizona and Florida.
Participants:
A total of 1138 non-pediatric inpatients from all units across the hospital.
Intervention:
GTT was applied to randomly selected medical records with independent assessments of two registered nurses with a physician review for confirmation.
Main Outcome Measure:
The Cohen Kappa coefficient was used as a measure of inter-rater agreement. The positive predictive value was assessed for individual triggers.
Results:
Good levels of reliability were obtained between independent nurse reviewers at the case-level for both the occurrence of any trigger and the identification of an adverse event. Nurse reviewer agreement for individual triggers was much more varied. Higher agreement appears to occur among triggers that are objective and consistently recorded in selected portions of the medical record. Individual triggers also varied on their yield to detect adverse events. Cases with adverse events had significantly more triggers identified (mean 4.7) than cases with no adverse events (mean 1.8).
Conclusions:
The trigger methodology appears to be a promising approach to the measurement of patient safety. However, automated processes could make the process more efficient in identifying adverse events and has a greater potential of improving care delivery and patient 'outcomes'.
Insights
The Global Trigger Tool (GTT) shows good reliability for identifying patient safety events in hospitals. Individual trigger reliability varied, suggesting potential for automated improvements in patient care.
Area of Science:
- Patient Safety Research
- Healthcare Quality Improvement
- Clinical Informatics
Background:
- Measuring patient safety events is crucial for improving healthcare quality.
- The Global Trigger Tool (GTT) is a method used to identify adverse events.
- Assessing the reliability of GTT in practice settings is essential.
Purpose of the Study:
- To evaluate the inter-rater reliability of the GTT.
- To explore the effectiveness of individual triggers within the GTT.
- To assess GTT's utility in a real-world clinical environment.
Main Methods:
- Prospective application of the GTT to 1138 inpatient records across four US hospitals.
- Independent review of medical records by two registered nurses, with physician confirmation.
- Analysis using Cohen Kappa coefficient for inter-rater agreement and positive predictive value for triggers.
Main Results:
- High case-level reliability was achieved for identifying any trigger and adverse events.
- Inter-rater agreement for individual triggers was variable, with higher agreement for objective, consistently recorded triggers.
- Adverse event cases had significantly more triggers identified (mean 4.7) than non-adverse event cases (mean 1.8).
Conclusions:
- The GTT methodology is a promising approach for measuring patient safety.
- Individual trigger performance varies, impacting reliability.
- Automation could enhance efficiency and improve patient outcomes.
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