Developing and Evaluating an Automated All-Cause Harm Trigger System

Christine Sammer, Susanne Miller, Cason Jones, Antoinette Nelson, Paul Garrett, David Classen, David Stockwell

Research output: Contribution to journalArticle

Abstract

Background From 2009 through 2012, the Adventist Health System Patient Safety Organization (AHS PSO) used the Global Trigger Tool method for harm identification and demonstrated harm reduction. Although the awareness of harm demonstrated opportunities for improvement across the system, leaders determined that the human and fiscal resources required to continue with a retrospective manual harm identification process were unsustainable. In addition, there was growing concern that the identification of harm after the patient's discharge did not allow for intervention during the hospital stay. Therefore, the AHS PSO decided to seek an alternative method for patient harm identification. Methods The AHS PSO and another PSO jointly developed a novel automated all-cause harm trigger identification system that allowed for real-time bedside intervention, real-time trend analysis affecting patient safety, and continued learning about harm measurement. A sociotechnical approach of people, process, and technology was used at two pilot hospitals sharing the same electronic health record platform. Automated positive harm triggers and work-flow models were developed and evaluated. Results Combined data from the two hospitals in a period of 11 consecutive months indicated (1) a total of 2,696 harms (combined hospital-acquired and outside-acquired); (2) that hypoglycemia (blood glucose ≤ 40 mg/dL) was the most frequently identified harm; (3) 256 harms related to the Patient Safety Indicator 90 (PSI 90) Composite descriptions versus 77 harms reported to regulatory harm reduction programs; and (4) that almost one third (32%) of total harms were classified as outside-acquired. Conclusion The automated harm trigger system revealed not only more harm but a broader scope of harm and led to a deeper understanding of patient safety vulnerabilities.

Original languageEnglish (US)
Pages (from-to)155-165
Number of pages11
JournalJoint Commission Journal on Quality and Patient Safety
Volume43
Issue number4
DOIs
StatePublished - Jan 1 2017
Externally publishedYes

Fingerprint

Patient Safety
Harm Reduction
Health
Patient Harm
Workflow
Patient Discharge
Electronic Health Records
Computer Systems
Hypoglycemia
Blood Glucose
Length of Stay
Learning
Technology

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Developing and Evaluating an Automated All-Cause Harm Trigger System. / Sammer, Christine; Miller, Susanne; Jones, Cason; Nelson, Antoinette; Garrett, Paul; Classen, David; Stockwell, David.

In: Joint Commission Journal on Quality and Patient Safety, Vol. 43, No. 4, 01.01.2017, p. 155-165.

Research output: Contribution to journalArticle

Sammer, Christine ; Miller, Susanne ; Jones, Cason ; Nelson, Antoinette ; Garrett, Paul ; Classen, David ; Stockwell, David. / Developing and Evaluating an Automated All-Cause Harm Trigger System. In: Joint Commission Journal on Quality and Patient Safety. 2017 ; Vol. 43, No. 4. pp. 155-165.
@article{3ab0673974f44ffa82761804dbda554f,
title = "Developing and Evaluating an Automated All-Cause Harm Trigger System",
abstract = "Background From 2009 through 2012, the Adventist Health System Patient Safety Organization (AHS PSO) used the Global Trigger Tool method for harm identification and demonstrated harm reduction. Although the awareness of harm demonstrated opportunities for improvement across the system, leaders determined that the human and fiscal resources required to continue with a retrospective manual harm identification process were unsustainable. In addition, there was growing concern that the identification of harm after the patient's discharge did not allow for intervention during the hospital stay. Therefore, the AHS PSO decided to seek an alternative method for patient harm identification. Methods The AHS PSO and another PSO jointly developed a novel automated all-cause harm trigger identification system that allowed for real-time bedside intervention, real-time trend analysis affecting patient safety, and continued learning about harm measurement. A sociotechnical approach of people, process, and technology was used at two pilot hospitals sharing the same electronic health record platform. Automated positive harm triggers and work-flow models were developed and evaluated. Results Combined data from the two hospitals in a period of 11 consecutive months indicated (1) a total of 2,696 harms (combined hospital-acquired and outside-acquired); (2) that hypoglycemia (blood glucose ≤ 40 mg/dL) was the most frequently identified harm; (3) 256 harms related to the Patient Safety Indicator 90 (PSI 90) Composite descriptions versus 77 harms reported to regulatory harm reduction programs; and (4) that almost one third (32{\%}) of total harms were classified as outside-acquired. Conclusion The automated harm trigger system revealed not only more harm but a broader scope of harm and led to a deeper understanding of patient safety vulnerabilities.",
author = "Christine Sammer and Susanne Miller and Cason Jones and Antoinette Nelson and Paul Garrett and David Classen and David Stockwell",
year = "2017",
month = "1",
day = "1",
doi = "10.1016/j.jcjq.2017.01.004",
language = "English (US)",
volume = "43",
pages = "155--165",
journal = "Joint Commission Journal on Quality and Patient Safety",
issn = "1553-7250",
publisher = "Joint Commission Resources, Inc.",
number = "4",

}

TY - JOUR

T1 - Developing and Evaluating an Automated All-Cause Harm Trigger System

AU - Sammer, Christine

AU - Miller, Susanne

AU - Jones, Cason

AU - Nelson, Antoinette

AU - Garrett, Paul

AU - Classen, David

AU - Stockwell, David

PY - 2017/1/1

Y1 - 2017/1/1

N2 - Background From 2009 through 2012, the Adventist Health System Patient Safety Organization (AHS PSO) used the Global Trigger Tool method for harm identification and demonstrated harm reduction. Although the awareness of harm demonstrated opportunities for improvement across the system, leaders determined that the human and fiscal resources required to continue with a retrospective manual harm identification process were unsustainable. In addition, there was growing concern that the identification of harm after the patient's discharge did not allow for intervention during the hospital stay. Therefore, the AHS PSO decided to seek an alternative method for patient harm identification. Methods The AHS PSO and another PSO jointly developed a novel automated all-cause harm trigger identification system that allowed for real-time bedside intervention, real-time trend analysis affecting patient safety, and continued learning about harm measurement. A sociotechnical approach of people, process, and technology was used at two pilot hospitals sharing the same electronic health record platform. Automated positive harm triggers and work-flow models were developed and evaluated. Results Combined data from the two hospitals in a period of 11 consecutive months indicated (1) a total of 2,696 harms (combined hospital-acquired and outside-acquired); (2) that hypoglycemia (blood glucose ≤ 40 mg/dL) was the most frequently identified harm; (3) 256 harms related to the Patient Safety Indicator 90 (PSI 90) Composite descriptions versus 77 harms reported to regulatory harm reduction programs; and (4) that almost one third (32%) of total harms were classified as outside-acquired. Conclusion The automated harm trigger system revealed not only more harm but a broader scope of harm and led to a deeper understanding of patient safety vulnerabilities.

AB - Background From 2009 through 2012, the Adventist Health System Patient Safety Organization (AHS PSO) used the Global Trigger Tool method for harm identification and demonstrated harm reduction. Although the awareness of harm demonstrated opportunities for improvement across the system, leaders determined that the human and fiscal resources required to continue with a retrospective manual harm identification process were unsustainable. In addition, there was growing concern that the identification of harm after the patient's discharge did not allow for intervention during the hospital stay. Therefore, the AHS PSO decided to seek an alternative method for patient harm identification. Methods The AHS PSO and another PSO jointly developed a novel automated all-cause harm trigger identification system that allowed for real-time bedside intervention, real-time trend analysis affecting patient safety, and continued learning about harm measurement. A sociotechnical approach of people, process, and technology was used at two pilot hospitals sharing the same electronic health record platform. Automated positive harm triggers and work-flow models were developed and evaluated. Results Combined data from the two hospitals in a period of 11 consecutive months indicated (1) a total of 2,696 harms (combined hospital-acquired and outside-acquired); (2) that hypoglycemia (blood glucose ≤ 40 mg/dL) was the most frequently identified harm; (3) 256 harms related to the Patient Safety Indicator 90 (PSI 90) Composite descriptions versus 77 harms reported to regulatory harm reduction programs; and (4) that almost one third (32%) of total harms were classified as outside-acquired. Conclusion The automated harm trigger system revealed not only more harm but a broader scope of harm and led to a deeper understanding of patient safety vulnerabilities.

UR - http://www.scopus.com/inward/record.url?scp=85020743889&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85020743889&partnerID=8YFLogxK

U2 - 10.1016/j.jcjq.2017.01.004

DO - 10.1016/j.jcjq.2017.01.004

M3 - Article

C2 - 28325203

AN - SCOPUS:85020743889

VL - 43

SP - 155

EP - 165

JO - Joint Commission Journal on Quality and Patient Safety

JF - Joint Commission Journal on Quality and Patient Safety

SN - 1553-7250

IS - 4

ER -