1. No category

Måling af patientskader
med IHI Global Trigger Tool
Lord Kelvin, 1902
© Science Museum/Science & Society pic lib
Patientsikkert Sygehus
Læringsseminar 5
November 2012
Hvad vil jeg tale om?
•  Hvad ved vi egentlig om validiteten og
metodens karakteristika i øvrigt?
•  Resultater fra to nye danske studier af
reproducerbarheden af GTT
Skade
Fejl
Død
Guldstandarden…
Metoder til identifikation af skader
•  OIG-studiet
–  Tilfældig stikprøve på 278 udskrivelser af Medicarepatienter fra to counties i en uge af august 2008
–  To trins-proces: Primær screening efterfulgt af
lægeligt review
–  Fem forskellige screeningmetoder
Antal og andel af fundne skader
Metode
Antal
Global Trigger Tool
POA-analyse
93
61
Interviews
UTH-rapporter
PSI-analyse
22
8
8
Andel af de 120
78 %
51 %
18 %
7%
7%
Metoder til identifikation af skader
•  Health Affairs 2011
–  Tilfældig stikprøve på 795 udskrivelser fra tre højt
specialiserede sygehuse i perioden 1.-31. oktober
2004
–  Tre forskellige screeningsmetoder
–  På ét af sygehusene foretog man lokalt lægeligt
review af den komplette journal + øvrige data på
samtlige patienter, der indgik
Identificerede skader efter
alvorlighed
E
F
GTT
204
214
PSI
23
7
UTH
0
2
G
H
I
I alt
8
14
4
354
1
0
4
35
2
0
0
4
Interrater reliability
•  North Carolina-studiet
–  2400 journaler fra patienter udskrevet fra ti tilfældigt
udvalgte hospitaler i perioden 1. januar 2002 til 31.
december 2007
–  Ti journaler pr. kvartal pr. hospital
•  Mayo-studiet
–  1138 indlæggelser fra tre Mayo-campuses i perioden
august 2004 til marts 2008 (delvist)
662
HSR: Health Services Research 46:2 (April 2011)
Figure 1: Description and Number of Medical Record Reviews, by Reviewer
Type (AE, Adverse Event)
North Carolina
2400 charts randomly selected
from 10 hospitals between 2002 and 2007
teams were frequently identified by the experienced review team as well (high
specificity). We did not identify enough adverse events in the more severe
categories of G, H, and I to determine with confidence the sensitivity and
specificity of the internal and external team reviews for these more severe
adverse events (Table 4).
North Carolina
Figure 4: Level of Agreement between Internal and External Review
Teams and the Experienced Review Team
Any adverse events
Internal
External
Number of adverse
events
Adverse event
severity
0
Slight
0.2
Fair
0.4
0.6
0.8
1
Moderate Substantial
Almost
perfect
Level of Agreement (Kappa)
1
2
3
4
5
6
7
8 or more
Mayo
242
205
156
111
73
46
25
55
211
147
112
65
34
15
14
8
31
58
44
46
39
31
11
47
12.8
28.3
28.2
41.4
53.4
67.4
44.0
85.4
26
35
26
25
14
13
2
15
5
23
18
21
25
18
9
32
Table 3 Agreement between nurse reviewers and between nurse and physician reviewers for identifying adverse events, by
site and overall
Site
Trigger/Adverse events
Reviewer pair
Simple Kappa coefficient
......................................................................
Coefficient
Lower CI
Upper CI
0.6312
0.5106
0.7109
0.7290
0.5965
0.7544
0.5777
0.4616
0.6628
0.5291
0.4026
0.7015
0.5804
0.4518
0.6775
0.6488
0.5128
0.7071
0.5034
0.3686
0.6058
0.3886
0.2469
0.6206
0.6820
0.5693
0.7443
0.8092
0.6803
0.8016
0.6520
0.5545
0.7198
0.6696
0.5584
0.7824
.............................................................................................................................................................................
Overall
Overall
Overall
A
A
A
B
B
B
C
C
C
Triggers
Adverse
Adverse
Triggers
Adverse
Adverse
Triggers
Adverse
Adverse
Triggers
Adverse
Adverse
events
events
events
events
events
events
events
events
RN1 – RN2
RN1 – RN2
RN – MD
RN1 – RN2
RN1 – RN2
RN – MD
RN1 – RN2
RN1 – RN2
RN – MD
RN1 – RN2
RN1 – RN2
RN – MD
Table 4 Agreement between nurse reviewers and between nurse and physician reviewers for identifying adverse events, by
year
Year
Trigger/Adverse events
Reviewer pair
Simple Kappa coefficient
Danske erfaringer
Downloaded from bmjopen.bmj.com on October 18, 2012 - Published by group.bmj.com
Open Access
Research
Experiences with global trigger tool
reviews in five Danish hospitals:
an implementation study
Christian von Plessen,1 Anne Marie Kodal,2 Jacob Anhøj3
To cite: von Plessen C,
Kodal AM, Anhøj J.
Experiences with global
trigger tool reviews in five
Danish hospitals:
an implementation study.
BMJ Open 2012;2:e001324.
ABSTRACT
Objectives: To describe experiences with the
implementation of global trigger tool (GTT) reviews in
five Danish hospitals and to suggest ways to improve
the performance of GTT review teams.
Design: Retrospective observational study.
ARTICLE SUMMARY
Article focus
▪ To describe experiences with the implementation
of global trigger tool (GTT) reviews in five
Danish hospitals.
Hvad ved vi så?
•  25 % af patienterne skades (18-33 %)
•  96 % af skaderne er mindre alvorlige og
forbigående (E-F)
•  Højst skaderate og størst andel mindre
alvorlige skader følges ad
Hillerød-studiet
•  Sammenligning af den fundne skaderate i to
uafhængige reviews af de to samme
perioder:
–  1. januar – 30. juni 2010
–  1. oktober 2011 – 31. marts 2012
–  Spørgsmål: Kan et erfarent team reproducere en
tidligere fundet skaderate ved måling på en ny
stikprøve fra samme periode?
Hillerød: udvikling i skaderaten
Skader per 1000 liggedage
200
180
160
140
120
100
80
60
40
20
0
Median Konklusion
•  Hvis reviewprocessen er stabil
–  Tror vi på at et fald er reelt
–  Kan vi ikke udelukke, at en stigning skyldes
– 
– 
Bedre dokumentation
Grundigere team
•  GTT er stadig det bedste overordnede mål
•  Betydeligt udviklingspotentiale
Tak for opmærksomheden!
• 
• 
• 
• 
• 
Adverse events in hospitals: Methods for identifying events. Washington, DC: U.S.
Department of Health and Human Services, Office of Inspector General; 2010
OEI-06-08-00221.
Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel
A, Seger A, James BC. “Global trigger tool” shows that adverse events in hospitals may
be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581-9.
Sharek PJ, Parry G, Goldmann D, Bones K, Hackbarth A, Resar R, et al. Performance
characteristics of a methodology to quantify adverse events over time in hospitalized
patients. Health Serv Res. 2011;46(2):654-78.
Naessens JM, O’Byrne TJ, Johnson MG, Vansuch MB, McGlone CM, Huddleston JM.
Measuring hospital adverse events: assessing inter-rater reliability and trigger
performance of the Global Trigger Tool. Int J Qual Health Care. 2010;22(4):266-74.
Solberg LI, Mosser G, McDonald S. The three faces of performance measurement:
Improvement, accountability, and research. Joint Commission Journal on Quality
Improvement. 1997; 23(3):135-47.