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Journal Article > Study

Developing and evaluating an automated all-cause harm trigger system.

Sammer C, Miller S, Jones C, et al. Jt Comm J Qual Patient Saf. 2017;43:155–165.

Trigger tools seek to identify adverse events by flagging cases for review based on a particular data point (the "trigger"). Investigators, working through a Patient Safety Organization, sought an alternative to the widely used Institute for Healthcare Improvement Global Trigger Tool, one that would require less time and fewer resources. They developed a single, automated trigger encompassing a multitude of possible harms that could be implemented in real time. The most common harm identified by the novel trigger tool was hypoglycemia. The authors note that their tool detected more adverse events than the AHRQ Patient Safety Indicators. An accompanying editorial lauds this study as a step forward in efforts to harness the electronic health records to enhance patient safety through data analysis.

Journal Article > Study

Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.

Oliva EM, Bowe T, Tavakoli S, et al. Psychol Serv. 2017;14:34-49.

Opioid-related harm is an urgent patient safety priority. Identifying patients at higher risk of harm is a critical aspect of opioid safety. This quality improvement team developed a predictive model, based on electronic health record data, to identify high-risk opioid users in order to provide targeted monitoring and intervention via a clinical decision support tool. The model included known risk factors for opioid-related harm, such as type of medication, dose, and coprescribed sedating medications as well as medical and mental health conditions. Investigators developed and validated the model using data from 2010 and tested its ability to predict overdose or suicide attempt in 2011. The model successfully and prospectively identified patients at risk for suicide attempt or overdose. They then used the electronic health record to provide physicians with an overdose or suicide risk estimate and a checklist of risk mitigation strategies at the point of care. The authors suggest that further study of the implementation of this risk mitigation strategy in primary care is needed.

Journal Article > Study

Screening for medication errors using an outlier detection system.

Schiff GD, Volk LA, Volodarskaya M, et al. J Am Med Inform Assoc. 2017;24:281-287.

Medication errors continue to occur despite implementation of computerized provider order entry and clinical decision support systems. This study sought to assess whether medication error alerts might have a greater impact on mitigating such errors if they were generated based on outlier detection screening. Researchers analyzed data from the electronic health records of 747,985 outpatients to identify outliers that might indicate a medication error. They then chose 300 charts from the 15,693 resulting alerts. The charts were reviewed using a coding system to evaluate the utility of the alerts generated. About 75% of the chart-reviewed alerts created by the screening system identified possible medication errors. The authors suggest that using this type of outlier detection screening to generate alerts might improve existing clinical decision support systems' ability to mitigate medication errors. A prior WebM&M commentary discussed an incident involving an electronic prescribing error.

Journal Article > Study

Assessing frequency and risk of weight entry errors in pediatrics.

Hagedorn PA, Kirkendall ES, Kouril M, et al. JAMA Pediatr. 2017;171:392-393

Weight-based medication dosing can lead to medication errors in pediatric patients. Investigators used a trigger tool to detect weight-entry errors in the electronic health record. They found that dosing errors are rare and are most likely to occur in urgent and emergent settings. These findings suggest that a weight-entry trigger tool can identify pediatric patients at risk for dosing errors.

Journal Article > Study

Detection of adverse drug events using an electronic trigger tool.

Lim D, Melucci J, Rizer MK, Prier BE, Weber RJ. Am J Health Syst Pharm. 2016;73(17 suppl 4):S112-S120.

Trigger tools, which identify possible adverse events in administrative data as a precursor to chart review, are a core method to detect safety hazards. In this study, implementation of a trigger tool successfully uncovered adverse drug events, but there were a significant number of false positive triggers.

Journal Article > Study

Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records.

Kirkendall ES, Kouril M, Dexheimer JW, et al. J Am Med Inform Assoc. 2016 Aug 9; [Epub ahead of print].

The availability of decision support in computerized provider order entry (CPOE) systems has improved the ability to detect and prevent medication errors before they reach patients. However, when CPOE systems generate an excessive number of safety warnings that prescribers must manually override, alert fatigue may occur. In this study, investigators used a trigger tool approach and reviewed all antibiotic prescriptions with overridden alerts. They found that antibiotic prescriptions with overridden alerts were associated with dosing errors. In many cases, antibiotic overdoses reached patients and led to symptoms. The investigators used this data to refine the alert system, which eliminated some useless alerts. The authors conclude that automated algorithm-based detection systems can enhance the relevance of CPOE medication alerts and thereby reduce medication errors. A recent WebM&M commentary described a medication overdose related to alert fatigue.

Journal Article > Review

Identifying patients with sepsis on the hospital wards.

Bhattacharjee P, Edelson DP, Churpek MM. Chest. 2017;151:898-907.

Undiagnosed sepsis can lead to serious patient harm. This review describes proactive methods of monitoring patients to augment detection and early treatment of sepsis. The authors discuss how this process has evolved over time and suggest that automated tools can aid in identifying and managing sepsis.

Journal Article > Study

Computerized triggers of big data to detect delays in follow-up of chest imaging results.

Murphy DR, Meyer AND, Bhise V, et al. Chest. 2016;150:613-620.

Insufficient follow-up of test results is a known contributor to missed and delayed diagnosis. This observational study used a trigger tool to detect diagnostic delays related to chest imaging follow-up. Investigators used an automated algorithm to identify chest imaging cases that potentially had a follow-up delay. A clinician then reviewed the medical records for a random sample of cases identified by the trigger tool and a reference set of cases involving patients with abnormal test results but no delays. They found that the trigger tool had 99% sensitivity and 38% specificity in detecting delays in follow-up of abnormal chest imaging. The authors suggest that this trigger tool may help identify patients at risk for diagnostic delay following abnormal chest imaging. A WebM&M commentary discussed delayed follow-up of a diagnostic test.

Journal Article > Study

Can medical record reviewers reliably identify errors and adverse events in the ED?

Klasco RS, Wolfe RE, Lee T, et al. Am J Emerg Med. 2016;34:1043-1048.

Classic studies of the epidemiology of adverse events in hospitalized patients have identified safety issues using retrospective chart review combined with trigger tools. This study examined this methodology to detect adverse events in emergency department patients and found good agreement between independent clinical reviewers regarding the presence of errors and adverse events.

Journal Article > Study

Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery.

Menendez ME, Janssen SJ, Ring D. BMJ Qual Saf. 2016;25:25-30.

Trigger tools facilitate detection of adverse events in medical records, which enables more efficient record review. This study identified adverse events following outpatient orthopedic surgeries using a trigger tool. There was an overall adverse event rate of 10%, suggesting significant improvements are needed in this ambulatory surgery setting.

Journal Article > Study

Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings.

Murphy DR, Thomas EJ, Meyer AND, Singh H. Radiology. 2015;277:81-87.

Delays in follow-up of abnormal test results are known to contribute to delayed and missed diagnosis. Investigators developed and validated an electronic trigger to identify potential delays in follow-up of abnormal chest computed tomography scans. This study found that more than half of the flagged cases had a true diagnostic delay. This work should lead to prospective evaluation of trigger approaches to enhance test result follow-up.

Journal Article > Study

Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting.

Mull HJ, Rosen AK, Shimada SL, et al. EGEMS (Wash DC). 2015;3:1116.

Trigger tools have been shown to be an efficient way to screen for adverse events. This AHRQ-funded study assessed the usefulness of different adverse drug event triggers in the outpatient setting. Five of the triggers performed reasonably well for either detecting harm or leading to a change in care plan.

Journal Article > Study

Evaluation of an automated surveillance system using trigger alerts to prevent adverse drug events in the intensive care unit and general ward.

DiPoto JP, Buckley MS, Kane-Gill SL. Drug Saf. 2015;38:311-317.

A persistent challenge in patient safety is detecting and intervening in unsafe situations before patients are harmed. Trigger tools have been widely used in retrospective studies to identify and characterize adverse events, and this study reports on a novel use for triggers—detecting potentially harmful drug interactions during the computerized provider order entry process. Trigger alerts in a computerized provider order entry system at three hospitals (academic, community, and rural) were reviewed by a pharmacist, who then either personally made changes or contacted the prescribing physician. The triggers were developed by a multidisciplinary team involving clinicians and information technologists and were tailored to identify clinically significant medication errors. The authors found that more than 40% of the alerts required pharmacist intervention, and that over 90% of pharmacist recommendations were accepted by the prescribing physicians. Therefore, the triggers used in this study generated far fewer false-positive alerts than seen in other studies. The proliferation of false-positive warnings is a primary contributor to alert fatigue, and although this study did not directly measure this phenomenon, it is plausible that use of more tailored alerts could avert alarm fatigue.

Journal Article > Study

Monitoring the harm associated with use of anticoagulants in pediatric populations through trigger-based automated adverse-event detection.

Patregnani JT, Spaeder MC, Lemon V, Diab Y, Klugman D, Stockwell DC. Jt Comm J Qual Patient Saf. 2015;41:108-114.

Warfarin and other anticoagulant medications are known to place patients at high risk of adverse drug events across multiple settings. This retrospective study examined the safety of anticoagulant therapy in hospitalized children. Researchers used a trigger approach in which abnormal laboratory test values were used to identify medical records which were reviewed for the presence or absence of an adverse drug event, an approach that has been used in other settings. They also used the administration of a reversal agent, protamine, as a trigger to detect adverse drug events. Relatively few adverse events were identified in comparison to the high number of records screened. These findings underscore the need for more sophisticated automated rules to enhance trigger-based identification of adverse drug events. A past AHRQ WebM&M commentary discussed the hazards related to prescribing warfarin and best practices to reduce risks associated with anticoagulant use.

Journal Article > Review

Clinical criteria to screen for inpatient diagnostic errors: a scoping review.

Shenvi EC, El-Kareh R. Diagnosis. 2014;2:3-19.

This review determined several candidate trigger criteria for retrospectively identifying diagnostic errors in hospitalized patients. These included triggers that are already in use for detecting adverse events (such as cardiopulmonary arrest or unplanned transfer to a higher level of care) and novel triggers (including change in code status and need for multiple subspecialty consults).

Journal Article > Study

Optimization of drug–drug interaction alert rules in a pediatric hospital's electronic health record system using a visual analytics dashboard.

Simpao AF, Ahumada LM, Desai BR, et al. J Am Med Inform Assoc. 2015;22:361-369.

Researchers used rapid-cycle iterative interventions to improve drug interaction alerts by eliminating clinically irrelevant notifications. These efforts resulted in fewer alerts and fewer manual overrides of alerts without any serious safety events, emphasizing the often cited need to streamline clinical decision support to prevent alarm fatigue.

Journal Article > Study

Development of an electronic pediatric all-cause harm measurement tool using a modified Delphi method.

Stockwell DC, Bisarya H, Classen DC, et al. J Patient Saf. 2016;12:180-189.

Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.

Journal Article > Commentary

A medication-based trigger tool to identify adverse events in pediatric anesthesiology.

Taghon T, Elsey N, Miler V, McClead R, Tobias J. Jt Comm J Qual Patient Saf. 2014;40:326-334.

This commentary describes the development of a trigger tool initiative to detect and record adverse events in pediatric anesthesiology. The process included identifying which medications to track, creating a search mechanism, implementing the tool, and disseminating the data.

Journal Article > Study

Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.

Call RJ, Burlison JD, Robertson JJ, et al. 2014;165:447-452.

To investigate the utility of a trigger tool in detecting adverse drug events (ADEs) in pediatric hematology and oncology patients, this study compared the tool with a voluntary reporting system. Implementation of the trigger tool led to inclusion of many cases that were not ADEs (false positives). In contrast, voluntary reporting did not identify all ADEs that were found using the trigger tool, implying under-reporting. These results reinforce prior research suggesting that multiple detection methods are needed to comprehensively detect ADEs. The authors advocate for triggers to be refined according to patient population and hospital setting to augment their usefulness. A previous AHRQ WebM&M perspective discusses the role of trigger tools in identifying ADEs and measuring patient safety.

Journal Article > Study

Detection of adverse events in an acute geriatric hospital over a 6-year period using the Global Trigger Tool.

Suarez C, Menendez MD, Alonso J, Castaño N, Alonso M, Vazquez F. J Am Geriatr Soc. 2014;62:896-900.

This retrospective study employed the Global Trigger Tool to detect adverse events at a geriatric hospital and found that incidents declined over time. The authors attribute improvements to systems strategies, including checklists, safety culture surveys, and prevention of pressure ulcers and infections.

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