Summary of Studies included in a Systematic Review of Trigger Tools to Identify Preventable Adverse Events in the Outpatient Setting
| First Author Last Name | Patients (N) | How pAE Was Measured | AEs Evaluated | pAE Detection Rate | Triggers Used (Details within Footnotes) | No. of Triggers | Manual Review (M), Computerized Data Method (C), or both (B) |
|---|---|---|---|---|---|---|---|
| Bigby et al.36 | General, from discharge records (N = 527) | Screened by investigator, reviewed by 3 blinded, independent physicians | Any pAE, classified as drug or follow-up related | 9% preventable admissions* | Hospital admission | 685 emergency admissions | C |
| Brenner et al.37 | Adults seeking primary or urgent care, mean age 55 (N = 516) | Independent chart review by 2 physicians | pADE | 0.64% pADEs 13.5% ameliorable | Abnormal lab results† | 1342 triggers (1322 excluded) | C |
| DeWet et al.20 | Urban PC (N = 500) | Record review, initially independent (5 physicians and 2 nurses) | Any pAE | 5.4% for pAE,9.4% for AE | >3 visits per week, >10 consults per year, laboratory abnormalities, ED visit, hospital admission‡ | 730 triggers | M |
| Field et al.33 | Medicare enrollees over 65 years old who received health care in one of the group practices | Chart review, screened by pharmacist, reviewed by 2 independent physicians | pADE | 1.8% pADE rate 9.2% after pharmacist screening | Hospitalization, ED visit, and abnormal lab result§ | 23,917 triggers | B |
| Gandhi et al.38 | General patients with at least one visit to the clinic, mean age 47 to 48 years old (N = 68,013) | Charts screened by “trained reviewers”, then reviewed by 2 independent clinicians including at least one physician | pADE | 0.7% overall 0.1% for laboratory rules 0.05% for drug-laboratory rules | Abnormal lab results¶ | 48,479 “incidents projected” for all triggers | B |
| Hibbert et al.34 | Patients aged >75 years old who had attended the practice at least 3 times over 6 months (N = 428) | Manual review by trained nurse | Any pAE | 4.8% pAE, not separated | >3 visits per week, hospital admission, ED visit, abnormal laboratory result‖ | 273 records with one or more triggers | M |
| Honigman et al.39 | General patients with at least one visit (N = 23,064) | Chart review by 4 independent physicians | Any pADE | 38% overall | Abnormal laboratory results*** | 1,802 abnormal labs, 25,056 overall | C |
| Lederer et al.40 | All patients on warfarin | Chart reviewed by Pharmacist, verified by physician | Grade C-I (harmful) pADE related to warfarin use | Approximately 13% | Abnormal lab (INR), also monitored for ED or hospital admission related to warfarin use†† | Unclear | C |
| Macnee et al.41 | General patients with one of five predefined “untoward events” (N = 1,111) | Chart review/screening medical charts by trained nurses or medical record room staff | “Untoward event”: hospitalization related to missed cancer diagnosis due to inadequate care | 84% for breast cancer 92% for rectal cancer | Hospital admission for missed cancer diagnosis‡‡ | 507 patients with untoward events related to missed cancer | C |
| Mathew et al.42 | Nursing home residents >60 years old with CKD (N = 5,449) | Research database (SPARCS: Statewide planning and research cooperative) | Potentially preventable hospitalizations (ambulatory care sensitive hospitalizations) | 29.3% (Sensitivity = 57.9%, Specificity = 48.9%) | Polypharmacy§§ | 2,883 patients with polypharmacy | C |
| McKay et al.35 | 175 “high risk” patients with COPD or ischemic heart disease or homebound and 345 patients >7 years old with ischemic heart disease (N = 520) | Chart review by physician trainees | Any “patient safety incident” | 7.7%, not separated | >3 consults, medication change, hospital admission, ED visit, abnormal labs¶¶ | 468 triggers | M |
| Obreli-neto et al.43 | Patients ≥60 years old (N = 433) | Manual review, consensus of majority of at least 3 pharmacists | Drug-drug interaction related pADEs | 0.9% (13% preventable, 87% ameliorable), not separated | Abnormal laboratory results‖‖ | 433 triggers | M |
| Payne et al.44 | Adults with long term chronic conditions (N = 180,815) | National Health Service data | Preventable admissions, defined by standard NHS Scotland list | 19.5% for >6 medications 24.8% for >10 medications | Polypharmacy*** | 18,495 > 6 medications, 8250 > 10 medications | M |
| Rev Prescrire31 | Discharged from general medicine or surgical wards (N = 2,946) | Chart review | Any pAE | 1.80% | Hospitalization††† | 2,946 patients hospitalized | Unclear |
| Singh et al.17 | Elderly patients with cardiovascular disease (N = 1,289) | Chart review by unblended physician/pharmacist teams | pADE | 24% in all charts reviewed 9.3% for medication stop 16.3% for hospitalization 9.0% for ED visit 30.6% for abnormal laboratory | Medication stop, hospitalization, ED visit, abnormal lab‡‡‡ | 645 charts with at least one trigger, 383 charts reviewed | M |
↵* 2.2% due only to patient compliance, 6.8% due to iatrogenic or combination.
↵† INR, SCr, BUN, AST, ALT, and TSH undetectable while on levothyroxine.
↵‡ Old version of IHI Tool included new allergy code, new “high priority code.”
↵§ Drug levels, electrolytes, liver and kidney function, INR, blood counts, TSH, C. difficile, and HbA1C; also included provider incident reports and electronic note review.
↵¶ Also included ICD-diagnoses, free text note search, “miscellaneous rules”; potassium, INR, and SCr.
↵‖ INR, GFR, and Hgb.
↵** Multiple abnormal labs, also included text searches, allergy codes, and ICD-9 codes.
↵†† INR > 3 (also included if patient received Vitamin K).
↵‡‡ Hospitalization for breast or colon cancer; also assessed appendicitis ectopic pregnancy, and birth complications.
↵§§ >12 medications.
↵¶¶ Hgb and GFR; also included new allergy code, new “high priority code.”
↵‖‖ Also included subjective symptom review at follow-up visit.
↵*** Looked at polypharmacy for 4 to 6, 7 to 9, and >10 medications.
↵††† All patients admitted in a specific region of France.
↵‡‡‡ INR, TSH, SCr, BUN, ALT, AST, other labs with PPV < 5: drug levels, blood counts, K, Bili, ALP, C. difficile, HgbA1c, and antidote administration.
ADE, adverse drug event; AE, adverse event; ALP, alkaline phosphate; ALT, alanine transaminase; AST, aspartate transaminase; BUN, blood urea nitrogen; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; ED, emergency department; Hgb, hemoglobin; GFR, glomerular filtration rate; ICD, International Classification of Diseases; IHI, Institute for Healthcare Improvement; INR, international normalized ratio; pADE, preventable adverse drug event; pAE, preventable adverse event; PC, primary care; PPV, positive predictive value; SCr, serum creatinine; TSH, thyroid stimulating hormone.