Development and Usability Testing of a System to Detect Adverse Events and Medical Mistakes

Many inpatient hospital visits result in adverse events, and a disproportionate number of adverse events are thought to occur among vulnerable populations. The personal and financial costs of these events are significant at the individual, care team, and system levels. Existing methods for identifying adverse events, such as the Institute for Healthcare Improvement Global Trigger Tool, typically involve retroactive chart review to identify risks or triggers and then detailed review to determine whether and what type of harm occurred. These methods are limited in scalability and ability to prospectively identify triggers to enable intervention before an adverse event occurs. The purpose of this study was to gather usability feedback on a prototype of an informatics intervention based on the IHI method. The prototype electronic Global Trigger Tool collects and presents risk factors for adverse events. Six health professionals identified as potential users in clinical, quality improvement, and research roles were interviewed. Interviewees universally described insufficiencies of current methods for tracking adverse events and offered important information on desired future user interface features. A key next step will be to refine and integrate an electronic Global Trigger Tool system into standards-compliant electronic health record systems as a patient safety module.