Anne Matlow MD FRCPC Medical Director, Patient Safety Hospital for Sick Children, Toronto

1. The Role of Trigger Tools in Detecting Adverse Events in Hospitalized Children: Filling in the Blanks Anne Matlow MD FRCPC Medical Director, Patient Safety Hospital for Sick Children, Toronto Associate Director, Centre for Patient Safety University of Toronto NICHQ 2010

2. DISCLOSURE I am Canadian

3. And I won’t rub it in!!!

4. The Role of Trigger Tools in Detecting Adverse Events in Hospitalized Children: Filling in the Blanks Anne Matlow MD FRCPC Medical Director, Patient Safety Hospital for Sick Children, Toronto Associate Director, Centre for Patient Safety University of Toronto NICHQ 2010

5. Trigger tool

6. 9 year old girl. Fell out of bed. Presented to ER with decreased level of consciousnessand hypertension. Admitted to PICU. Management focused on determining cause of lethargy (CT, MRI) and treating hypertension. Nephrology consulted when BP still elevated. Elicited history from Mom of periorbital edema. Diagnosis post- infectious glomerulonephritis with hypertension and encephalopathy. On review, proteinuria and hematuria present on admission. Improved on antihypertensives and low sodium diet.

8. Unplanned admission pre Unplanned readmit within 12 months Hospital incurred injury Adverse drug event Unplanned transfer to ICU Unplanned transfer to another acute care hosp Unplanned return to OR Unplanned removal, injury or repair intra-operatively Other patient complications New neurological deficit Unexpected death Inappropriate discharge home Cardiac/ resp arrest / low APGAR score Injury related to delivery or abortion Hospital acquired infection/ sepsis Documented dissatisfaction with care Documentation or correspondence re litigation Any other undesirable outcomes SCREENING/EXPLICIT CRITERIA

10. Detecting Adverse Events Method AE/1000 admissions Incident Reports (2-8%) 5 Retrospective Chart Review 30 Stimulated Voluntary Reports 30 Automated Flags 55* Daily chart review 85 Automated Flags and Daily review 130* *triggers Jha J Am Med Inf Assoc 1998;5:305 O'Neil Ann Int Med 1993;119:370 Original slide courtesy of Dr Philip Hebert

11. Manual • Paper-based retrospective chart review • Semi-automated • Screening electronically + review manually • Prospective, Concurrent, Retrospective • Fully automated • Screening + reviewing electronically • Only some types of AEs • e.g. INR>6 in pts on warfarin, ICD-9 codes • Not if implicit judgement is required

12. Voluntary reporting and computerized surveillance not as good as chart review Manual Chart Review Computerized Surveillance Voluntary Reporting 67 3 20 331 205 Classen DC, Pestotnik S. Evans S et al. Computerized surveillance of adverse drug events in hospitalized patients. JAMA. 1991;226:2847

14. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note reviewSariBMJ  2007;334:79 • 324 patient safety incidents were identified in 230/1006 admissions (22.9%; 95% CI 20.3% to 25.5%). • 270 (83%) patient safety incidents were identified by case note review (TT) only, • 21 (7%) by the routine reporting system only, and 33 (10%) by both methods. • TT 12x more sensitive than routine reporting system

15. Trigger Tool 2 stage Review TRIGGERS ADVERSE EVENTS

16. Rate of Adverse Events without using Trigger Tools All adverse events: ~1.0-3 / 100 patients (Miller Pediatrics 2003 and 2004; Slonim Pediatrics 2003; Woods Pediatrics 2005; ) Adverse drug events: True: 2.1-11/ 100 admissions Potential: ADE 14.6/ 100 admissions 22-60% preventable(Kaushal JAMA 2001; Holdsworth APAM 2003; Kunac Pediatric Drugs 2009)

17. Adverse Events in the NICU Sharek et al. Pediatrics. 2006:118:1332-1340 • 74 per 100 admissions of which 56% preventable n=554

20. Incidence of Adverse Events and Negligence in Hospitalized Patients Brennan NEJM 1991

22. Adverse events and preventable adverse events in children Woods Peds 2005:115:155

23. Adverse events and preventable adverse events in childrenWoods D. Pediatrics. 2005 Jan;115:155-60.

24. Quality in Australian Health Care StudyWilson Med J Aust 1995

26. Diagnostic errors are commoncause of adverse events AE rate Diagnostic NY 1984 3.7% 7% Utah/Col 1992 2.9% 6.9% Australia 1992 16.6% 13.3% NZ 1998 13.1% 8% UK 1999 10.8% 4.2% Canada 2001 7.5% 10.6% Sweden 2003 14.2% 11.3% De Vries QSHC 2008; Soop IJQHC 2009

30. DIAGNOSTIC ERROR Graber Arch Int Med 2005 Occurrences for which diagnosis was • Unintentionally delayed (sufficient info was available earlier), • Wrong (another diagnosis was made before the correct diagnosis), or • Missed (no diagnosis was ever made), as judged from the eventual appreciation of more definitive information

31. CAN TRIGGER TOOLS HELP US IDENTIFY DIAGNOSTIC ERROR?

36. Sensitivity and Specificity of the Canadian Paediatric Trigger Tool 89 patients experienced at least 1 AE

37. Clinical Care Process vs #AE

38. Clinical Care Process vs #AE 11.4% of adverse events were diagnostic

39. Distribution of AEs by Age Category

40. DIAGNOSTIC ERROR Delayed diagnosis of post streptococcal glomerulonephritis in 9 year old. Presented with hypertension and decreased level of consciousness. Work up focused on neurological findings. Diagnosis actually glomerulonephritis with hypertension and encephalopathy. Delay in initiating appropriate treatment. Improved on antihypertensives and low sodium diet.

41. CAN TRIGGER TOOLS HELP US IDENTIFY DIAGNOSTIC ERROR? METHODOLOGY DEPENDENT

42. CPTT

44. Focused Chart Review - Facilitates standardized second phase chart review More efficient Better to show improvement over time? Complete Chart Review ? Finds more AEs? ? Can find different AEs eg diagnostic error? Two types of Second stage review

45. FOCUSING ON DIAGNOSTIC ERROR WILL FILL IN A BLANK