This commentary describes a four-step process to help frontline caregivers identify and address safety concerns, such as interruptions in daily work.

Despite numerous studies over the past three decades, one fundamental patient safety question remains controversial: what proportion of hospitalized patients are harmed by medical care? Prior estimates range from approximately 3% to nearly 17%, but this study found that nearly one-third of patients experienced an adverse event during hospitalization. This study used the Institute for Healthcare Improvement's Global Trigger Tool to detect adverse events and also found that this trigger tool identified significantly more adverse events than voluntary reporting or the AHRQ Patient Safety Indicators. An important caveat is that this study did not assess whether the adverse events detected were preventable. Nevertheless, the results do raise the concern that adverse events remain common despite enhanced safety efforts. The challenges of accurately measuring patient safety events were discussed in an AHRQ WebM&M perspective.

This study found satisfactory reliability between internal and external reviewers using the IHI Global trigger tool to identify adverse hospital events.

Trigger tools have proved to be an effective method of screening for adverse events, with past research demonstrating their utility in the intensive care unit and pediatric hospitals. This study outlines the Institute for Healthcare Improvement Global Trigger Tool methodology and evaluates a refined process to improve the interrater reliability of the tool in practice. The authors found that a high level of interrater reliability was possible with well-trained primary (nonphysician) and secondary (physician) reviewers in this modified two-step approach.

This study describes the use of a focused chart review method centered around identification of triggers associated with adverse events (AEs). Non-physician reviewers at 54 hospitals screened charts for evidence of 23 clinical events, such as chest tube insertion, code status change, or readmission to the intensive care unit (ICU). If any of these triggers were present, the relevant portion of the chart was reviewed using methodology similar to the Harvard Medical Practice Study, and a physician confirmed the presence and severity of any AE identified. The authors found a rate of 11.3 AEs per 1000 patient-days, consistent with prior research, although this includes both preventable and non-preventable AEs. The authors state that using this focused review process to screen for AEs in the ICU can provide data to use in appropriately targeting patient safety measures.

This study examines the utility of root cause analysis (RCA) to identify, investigate, and address reported adverse drug events (ADEs). Discussion includes a description of the RCA system employed, examples of events analyzed, and an informative table sharing systematic changes resulting from the analyses. Although the intervention produced several opportunities for improvement, the emphasis also required a blame-free atmosphere and institutional support. The authors conclude that systematic application of root cause analysis, coupled with implementation of process changes, can serve as a powerful mechanism for institutional improvement.