Research ArticleOriginal Research

The Accuracy of Trigger Tools to Detect Preventable Adverse Events in Primary Care: A Systematic Review

Joshua Davis, Nicole Harrington, Heather Bittner Fagan, Barbara Henry and Margot Savoy
The Journal of the American Board of Family Medicine January 2018, 31 (1) 113-125; DOI: https://doi.org/10.3122/jabfm.2018.01.170247

References

  1. 1.↵
    Institute of Medicine. To err is human: Building a safer health system. Washington, DC: The National Academies Press, 2000.
  2. 2.↵
    1. Wachter RM
    . Patient safety at ten: Unmistakable progress, troubling gaps. Health Aff (Millwood) 2010;29:165–73.
    OpenUrlAbstract/FREE Full Text
  3. 3.↵
    1. Gandhi TK,
    2. Lee TH
    . Patient safety beyond the hospital. N Engl J Med 2010;363:1001–3.
    OpenUrlCrossRefPubMedWeb of Science
  4. 4.↵
    Agency for Healthcare Research and Quality. Patient safety in ambulatory care. July 2016. Available from: https://psnet.ahrq.gov/primers/primer/16. Accessed June 17, 2017.
  5. 5.↵
    American Hospital Association. Chartbook: Trends affecting hospitals and health systems. Chart 3.9 and 3.10. Available from: http://www.aha.org/research/reports/tw/chartbook/ch3.shtml. 2016. Accessed June 17, 2017.
  6. 6.↵
    Center for Disease Control and Prevention: National Center for Health Statistics. Ambulatory care use and physician office visits. June 13, 2016. Available from: http://www.cdc.gov/nchs/fastats/physician-visits.htm. Accessed June 17, 2017.
  7. 7.↵
    1. Brennan TA,
    2. Leape LL,
    3. Laird NM,
    4. et al
    . Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370–6.
    OpenUrlCrossRefPubMedWeb of Science
  8. 8.↵
    1. Thomas EJ,
    2. Brennan TA
    . Incidence and types of preventable adverse events in elderly patients: Population based review of medical records. Br Med J 2000;320:741–4.
    OpenUrlAbstract/FREE Full Text
  9. 9.↵
    1. Hanskamp-Sebregts M,
    2. Zegers M,
    3. Vincent C,
    4. van Gurp PJ,
    5. de Vet HC,
    6. Wollersheim H
    . Measurement of patient safety: A systematic review of the reliability and validity of adverse event detection with record review. BMJ Open 2016;6:e011078.
    OpenUrlAbstract/FREE Full Text
  10. 10.↵
    1. Sari ABA,
    2. Sheldon TA,
    3. Cracknell A,
    4. et al
    . Sensitivity of routine systems for reporting patient safety incidents in an NHS hospital: Retrospective patient case note review. Br Med J 2007;334:79–82.
    OpenUrlAbstract/FREE Full Text
  11. 11.↵
    1. Cullen DJ,
    2. Bates DW,
    3. Small SD,
    4. Cooper JB,
    5. Nemeskal AR,
    6. Leape LL
    . The incident reporting system does not detect adverse drug events: A problem for quality improvement. Jt Comm J Qual Improv 1995;21:541–8.
    OpenUrlPubMed
  12. 12.↵
    1. Murff HJ,
    2. Patel VL,
    3. Hripcsak G,
    4. Bates DW
    . Detecting adverse events for patient safety research: A review of current methodologies. J Biomed Inform 2003;36(1–2):131–143.
    OpenUrlCrossRefPubMedWeb of Science
  13. 13.↵
    1. Localio AR,
    2. Weaver SL,
    3. Landis JR
    . Identifying adverse events caused by medical care: Degree of physician agreement in a retrospective chart review. Ann Intern Med 1996;125:457–64.
    OpenUrlCrossRefPubMedWeb of Science
  14. 14.↵
    1. Resar RK,
    2. Rozich JD,
    3. Classen D
    . Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 2003;12(Suppl 2):39–45.
    OpenUrl
  15. 15.↵
    1. Spencer R,
    2. Cambell SM
    . Tools for primary care patient safety: A narrative review. BMC Fam Pract 2014;15:166.
    OpenUrlCrossRefPubMed
  16. 16.↵
    National Health Service. The primary care trigger tool: practical guidance for GP team. Available from: http://www.nes.scot.nhs.uk/media/6361/Primary%20Care%20Trigger%20Tool%20-%20Practical%20Guidance.pdf. 2010. Accessed June 17, 2017.
  17. 17.↵
    1. Singh R,
    2. McLean-Plunckett EA,
    3. Kee R,
    4. et al
    . Experience with a trigger tool for identifying adverse drug events among older adults in ambulatory primary care. Qual Saf Health Care 2009;18:199–204.
    OpenUrlAbstract/FREE Full Text
  18. 18.↵
    Institute for Healthcare Improvement. IHI Outpatient Adverse Event Trigger Tool. Available from: http://www.ihi.org/resources/Pages/Tools/OutpatientAdverseEventTriggerTool.aspx. October 2006. Accessed June 17, 2017.
  19. 19.↵
    1000 Lives. Tools for improvement: How to use trigger tools. April 2012. Available from: http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/T4I%20%284%29%20How%20to%20use%20Trigger%20Tools%20%28Feb%202011%29%20Web.pdf. Accessed June 17, 2017.
  20. 20.↵
    1. de Wet C,
    2. Bowie P
    . The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records. Postgrad Med J 2009;85:176–80.
    OpenUrlAbstract/FREE Full Text
  21. 21.↵
    1. Hibbert PD,
    2. Molloy CJ,
    3. Hooper TD,
    4. et al
    . The application of the Global Trigger Tool: A systematic review. Int J Qual Health Care 2016;28:640–9.
    OpenUrl
  22. 22.↵
    1. Henriksen K,
    2. Battles JB,
    3. Marks ES,
    4. Lewin DI
    1. Kizer KW,
    2. Stegun MB
    . Serious reportable adverse events in health care. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in patient safety: From research to implementation (Volume 4: Programs, tools, and products). Rockville, MD: Agency for Healthcare Research and Quality (US); 2005.
  23. 23.↵
    1. Hatoun J,
    2. Chan JA,
    3. Yaksic E,
    4. et al
    . A systematic review of patient safety measures in adult primary care. Am J Med Qual 2017;32:237–45.
    OpenUrl
  24. 24.↵
    1. Lydon S,
    2. Cupples ME,
    3. Murphy AW,
    4. Hart N,
    5. O'Connor P
    . A systematic review of measurement tools for the proactive assessment of patient safety in general practice. J Patient Saf 2017 Apr 4 [Epub ahead of print].
  25. 25.↵
    1. Panesar SS,
    2. deSilva D,
    3. Carson-Stevens A,
    4. et al
    . How safe is primary care? A systematic review. BMJ Qual Saf 2016;25:544–53.
    OpenUrlAbstract/FREE Full Text
  26. 26.↵
    1. Tsang C,
    2. Majeed A,
    3. Aylin P
    . Routinely recorded patient safety events in primary care: A literature review. Fam Pract 2012;29:8–15.
    OpenUrlCrossRefPubMedWeb of Science
  27. 27.↵
    1. Moher D,
    2. Liberati A,
    3. Tetzlaff J,
    4. Altman DG
    . Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Int J Surg 2010;8:336–41.
    OpenUrlCrossRefPubMed
  28. 28.↵
    1. Jüni P,
    2. Witschi A,
    3. Bloch R,
    4. Egger M
    . The hazards of scoring the quality of clinical trials for meta-analysis. JAMA 1999;282:1054–60.
    OpenUrlCrossRefPubMedWeb of Science
  29. 29.↵
    National Heart, Lung, and Blood Institute. Quality assessment tool for observational cohort and cross-sectional studies. March 2014. Available from:https://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/tools/cohort. Accessed June 17, 2017.
  30. 30.↵
    Essential Items for Reporting Diagnostic Accuracy Studies. Stard-Statement.org, The EQUATOR Network, www.stard-statement.org/. Accessed 1 Sept. 2017.
  31. 31.↵
    Ambulatory care in France: Too many adverse events. Rev Prescrire 2012;21:40–1.
    OpenUrl
  32. 32.↵
    1. Michel P,
    2. Quenon JL,
    3. Djihoud MA,
    4. Bru Sonnet R
    . Les événements indésirables liés aux soins extra-hospitaliers : Fréquence et analyse approfondie des causes (etude EVISA). Available from: http://solidarites-sante.gouv.fr/IMG/pdf/Rapport_EVISAfinal_17aout09.pdf. 2008. Accessed June 17, 2017.
  33. 33.↵
    1. Field TS,
    2. Gurwitz JH,
    3. Harrold LR,
    4. et al
    . Strategies for detecting adverse drug events among older persons in the ambulatory setting. J Am Med Inform Assoc 2004;11:492–8.
    OpenUrlCrossRefPubMed
  34. 34.↵
    1. Hibbert P,
    2. Williams H
    . The use of a global trigger tool to inform quality and safety in Australian general practice: A pilot study. Aust Fam Physician 2014;43:723–6.
    OpenUrlPubMed
  35. 35.↵
    1. McKay J,
    2. de Wet C,
    3. Kelly M,
    4. Bowie P
    . Applying the trigger review method after a brief educational intervention: potential for teaching and improving safety in GP specialty training? BMC Med Educ 2013;13:117.
    OpenUrlCrossRefPubMed
  36. 36.↵
    1. Bigby J,
    2. Dunn J,
    3. Goldman L,
    4. et al
    . Assessing the preventability of emergency hospital admissions. A method for evaluating the quality of medical care in a primary care facility. Am J Med 1987;83:1031–6.
    OpenUrlCrossRefPubMedWeb of Science
  37. 37.↵
    1. Brenner S,
    2. Detz A,
    3. López A,
    4. Horton C,
    5. Sarkar U
    . Signal and noise: Applying a laboratory trigger tool to identify adverse drug events among primary care patients. BMJ Qual Saf 2012;21:670–5.
    OpenUrlAbstract/FREE Full Text
  38. 38.↵
    1. Gandhi TK,
    2. Seger AC,
    3. Overhage JM,
    4. et al
    . Outpatient adverse drug events identified by screening electronic health records. J Patient Saf 2010;6:91–6.
    OpenUrlCrossRefPubMed
  39. 39.↵
    1. Honigman B,
    2. Lee J,
    3. Rothschild J,
    4. et al
    . Using computerized data to identify adverse drug events in outpatients. J Am Med Inform Assoc 2001;8:254–66.
    OpenUrlCrossRefPubMed
  40. 40.↵
    1. Lederer J,
    2. Best D
    . Reduction in anticoagulation-related adverse drug events using a trigger-based methodology. Jt Comm J Qual Patient Saf 2005;31:313–8.
    OpenUrlPubMed
  41. 41.↵
    1. Macnee CL,
    2. Penchansky R
    . Targeting ambulatory care cases for risk management and quality management. Inquiry 1994;31:66–75.
    OpenUrlPubMed
  42. 42.↵
    1. Mathew R,
    2. Young Y,
    3. Shrestha S
    . Factors associated with potentially preventable hospitalization among nursing home residents in New York State with chronic kidney disease. J Am Med Dir Assoc 2012;13:337–43.
    OpenUrlCrossRefPubMed
  43. 43.↵
    1. Obreli-Neto PR,
    2. Nobili A,
    3. de Oliveira Baldoni A,
    4. et al
    . Adverse drug reactions caused by drug–drug interactions in elderly outpatients: A prospective cohort study. Eur J Clin Pharmacol 2012;68:1667–76.
    OpenUrlPubMed
  44. 44.↵
    1. Payne RA,
    2. Abel GA,
    3. Avery AJ,
    4. Mercer SW,
    5. Roland MO
    . Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Br J Clin Pharm 2014;77:1073–82.
    OpenUrlCrossRefPubMed
  45. 45.↵
    Agency for Healthcare Research and Quality. Measurement of patient safety. July 2016. Available from: https://psnet.ahrq.gov/primers/primer/35/measurement-of-patient-safety. Accessed June 17, 2017.
  46. 46.
    1. Henriksen K,
    2. Battles JB,
    3. Keyes MA,
    4. Grady ML
    1. Pronovost P
    . Improving the value of patient safety reporting systems. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in patient safety: New directions and alternative approaches (Vol. 1: Assessment). Rockville, MD: Agency for Healthcare Research and Quality; 2008.
  47. 47.↵
    1. Chaho A
    . To pay or not to pay: Medicare and the preventable adverse event: A rational decision of dangerous philosophical change. J Law Health 2009;22:91–136.
    OpenUrl
  48. 48.↵
    Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. July 19, 2001. Available from: http://www.iom.edu/CMS/8089/5432.aspx. Accessed June 17, 2017.
  49. 49.↵
    1. Jha AK,
    2. Kuperman GJ,
    3. Teich JM,
    4. et al
    . Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 1998;5:305–14.
    OpenUrlCrossRefPubMed
  50. 50.↵
    1. Van Doormaal JE,
    2. Mol PGM,
    3. Van Den Bemt PMLA,
    4. et al
    . Reliability of the assessment of preventable adverse drug events in daily clinical practice. Drug Saf 2008;17:645–54.
    OpenUrl
  51. 51.↵
    1. Michel P,
    2. Quenon JL,
    3. de Sarasqueta AM,
    4. Scemama O
    . Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. Br Med J 2004;328:199–204.
    OpenUrlAbstract/FREE Full Text
  52. 52.↵
    1. Rafter N,
    2. Hickey A,
    3. Condell S,
    4. et al
    . Adverse events in healthcare: Learning from mistakes. QJM 2015;108:273–7.
    OpenUrlCrossRefPubMed
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