Detecting Harm to Prevent Adverse Events and Death

In a recent study led by David C. Stockwell, MD, MBA (Division of Critical Care Medicine, Department of Pediatrics, School of Medicine, The George Washington University; Center for Quality and Improvement Science, Children’s National Medical Center), researchers looked at whether using a trigger tool would identify the most common causes of harm in pediatric inpatient environments.

The trigger tool was modeled after the Institute for Healthcare Improvement’s adult-focused Global Trigger Tool. The IHI trigger tool counts only adverse events that cause harm to patients, whether or not a result of a medical error, and include events such as:

  • oversedation and lethargy
  • falls
  • transfers to a higher level of care

Dr. Stockwell and his team did a retrospective chart review of patients discharged in February 2012. A random sample of 100 patients from each site was included in the study.

Researchers found:

Of the 240 total events, 108 (45.0%) were assessed to have been potentially or definitely preventable. The most common patient harms were intravenous catheter infiltrations/burns, respiratory distress, constipation, pain, and surgical complications.

#IHI trigger tool detects 45% #AdverseEvents that were potentially or definitely preventable #ptsafety Click To Tweet

Might such a tool been able to detect and thereby prevent these deaths?


Amanda Abbiehl




John LaChance

Do you think the use of such a tool should be standard practice for all patients in hospital?

trigger tool should be standard practice for all #patients in #hospital #ptsafety Click To Tweet

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