Developing and Evaluating an Automated All-Cause Harm Trigger System.

Area of Science:

• Healthcare Informatics
• Patient Safety
• Clinical Quality Improvement

Background:

• The Adventist Health System Patient Safety Organization (AHS PSO) previously used the Global Trigger Tool for harm identification.
• Manual retrospective harm identification proved resource-intensive and lacked real-time intervention capabilities.
• The need for a more sustainable and timely patient harm identification method was identified.

Purpose of the Study:

• To develop and evaluate a novel automated all-cause harm trigger identification system.
• To enable real-time bedside intervention and trend analysis for patient safety.
• To enhance the understanding and measurement of patient harm.

Main Methods:

• A sociotechnical approach integrating people, process, and technology was employed.
• A new automated harm trigger identification system was jointly developed by two PSOs.
• The system was piloted at two hospitals with a shared electronic health record platform.

Main Results:

• Over 11 months, 2,696 harms were identified, including hospital-acquired and outside-acquired.
• Hypoglycemia was the most frequently identified harm.
• The automated system identified significantly more harms related to Patient Safety Indicator 90 (PSI 90) compared to regulatory reporting.

Conclusions:

• The automated harm trigger system identified a greater volume and wider range of patient harms.
• This system offers a deeper understanding of patient safety vulnerabilities.
• The findings support the utility of automated systems for proactive patient safety management.