Adventist Health’s trigger tool uncovers thousands of additional harm occurrences

After several years of using manual methods to identify and track patient harm, a real-time alert system helped Adventist Health System uncover thousands of additional instances of harm.

Over an 11-month period, an automated trigger tool uncovered nearly 2,700 instances of patient harm stemming from incidents both inside and outside the health system, according to a study published in The Joint Commission Journal for Patient Safety. Comparatively, the system’s manual method uncovered just 132 instances of patient harm during an 11-month period two years prior.

A major reason for the increase was the sheer number of records that the automated system could process through Adventist Health System's Patient Safety Organization. The trigger tool combed through more than 40,000 records compared to just 440 that were reviewed in the manual process.

Using harm definitions identified through the Institute for Healthcare Improvement’s Global Trigger Tool, Adventist Health built algorithms customized to the pilot hospital’s EHR system. Automated alerts were refined over the course of two years by observing the various levels of harm triggered by the system. Ultimately, 41 triggers were established to provide clinicians automated alerts.

Some of the most frequently identified instances of hospital-acquired harm included medication-induced hypoglycemia, Clostridium difficile infections, bleeding related to medication and blood clots.

Researchers pointed to several benefits associated with the shift to a real-time alert system, including the ability for clinicians to quickly find instances of harm, identify the cause and roll out necessary interventions.

“The automated trigger review process gave us the ability to identify patterns of harm as they evolved, allowing hospital quality departments the opportunity to respond proactively by providing awareness, education and intervention trainings as needed,” the researchers wrote.

The study echoes similar findings from a study at Boston Children’s Hospital published last year. There, researchers determined that a patient harm trigger tool could help measure patient safety initiatives across the institution.